Basic Information
| Provider Information | |||||||||
| NPI: | 1477545192 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | ANDREA | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 421 | ||||||||
| Address2: | |||||||||
| City: | LIBERTY LAKE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 990190421 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8667472455 | ||||||||
| FaxNumber: | 5092277070 | ||||||||
| Practice Location | |||||||||
| Address1: | 551 E HAWTHORNE RD | ||||||||
| Address2: | |||||||||
| City: | SPOKANE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 992181417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5092521900 | ||||||||
| FaxNumber: | 5092277070 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2005 | ||||||||
| LastUpdateDate: | 05/19/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD00038939 | WA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.