Basic Information
| Provider Information | |||||||||
| NPI: | 1386249506 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | BRYCE | ||||||||
| MiddleName: | PATRICK | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4231 TRAVIS ST # 8 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752054827 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9035202512 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5323 HARRY HINES BLVD | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753907201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2146483111 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/04/2020 | ||||||||
| LastUpdateDate: | 12/04/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/04/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | TX | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.