Basic Information
| Provider Information | |||||||||
| NPI: | 1063050367 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | BRANDON | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7540 N 19TH AVE STE 200 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850217967 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 7540 N 19TH AVE STE 200 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850217967 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8888734221 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/17/2019 | ||||||||
| LastUpdateDate: | 12/17/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/17/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.