Basic Information
| Provider Information | |||||||||
| NPI: | 1619235736 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | JASON | ||||||||
| MiddleName: | ALAN | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 850 HARVARD WAY # T5 | ||||||||
| Address2: | |||||||||
| City: | RENO | ||||||||
| State: | NV | ||||||||
| PostalCode: | 895022055 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7759825262 | ||||||||
| FaxNumber: | 7759825496 | ||||||||
| Practice Location | |||||||||
| Address1: | 975 RYLAND ST STE 100 | ||||||||
| Address2: | |||||||||
| City: | RENO | ||||||||
| State: | NV | ||||||||
| PostalCode: | 895021669 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7759825000 | ||||||||
| FaxNumber: | 7759825225 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2012 | ||||||||
| LastUpdateDate: | 04/02/2019 | ||||||||
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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 | 207Q00000X | 15746 | NV | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 15746 | 01 | NV | MD LICENSE NUMBER | OTHER | 12790436 | 01 | NV | CAQH | OTHER |