Basic Information
| Provider Information | |||||||||
| NPI: | 1104181171 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSTON | ||||||||
| FirstName: | BRENDAN | ||||||||
| MiddleName: | MICHAEL | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | FNP-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 41 MALL RD | ||||||||
| Address2: | LAHEY CLINIC | ||||||||
| City: | BURLINGTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 018050001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7817448000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 41 MALL RD | ||||||||
| Address2: | LAHEY CLINIC | ||||||||
| City: | BURLINGTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 018050001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7817448000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2012 | ||||||||
| LastUpdateDate: | 12/18/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | RN2259284 | MA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 110093601A | 05 | MA | MEDICAID |