Basic Information
| Provider Information | |||||||||
| NPI: | 1578850210 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | NICHOLAS | ||||||||
| MiddleName: | BRADFORD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 12358 | ||||||||
| Address2: | |||||||||
| City: | AUGUSTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 309142358 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7068639595 | ||||||||
| FaxNumber: | 7068688375 | ||||||||
| Practice Location | |||||||||
| Address1: | 3100 CHANNING WAY | ||||||||
| Address2: | |||||||||
| City: | IDAHO FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 834047533 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7068639595 | ||||||||
| FaxNumber: | 7068688375 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/01/2011 | ||||||||
| LastUpdateDate: | 05/20/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208200000X | 83999 | GA | N | Allopathic & Osteopathic Physicians | Plastic Surgery | 208200000X | 01076429A | IN | N | Allopathic & Osteopathic Physicians | Plastic Surgery | 208200000X | M-14721 | ID | Y | Allopathic & Osteopathic Physicians | Plastic Surgery |
No ID Information.