Individual
BRETT JOHANSEN
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA-C
Contact information
Practice address
1210 NW 16TH ST, FRUITLAND, ID 83619-2202
(208) 452-9881
Mailing address
1210 NW 16TH ST, FRUITLAND, ID 83619-2202
(208) 452-9881
Taxonomy
Speciality
Code
Description
License number
State
363AM0700X
Medical Physician Assistant
Primary
PA-1308
ID
Other
Enumeration date
10/07/2015
Last updated
10/07/2015
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