Healthcare Provider Details

I. General information

NPI: 1700948833
Provider Name (Legal Business Name): SCOTT PATRICK JOHNSON A.T.,C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1611 SCENIC DR
MODESTO CA
95355-4907
US

IV. Provider business mailing address

901 EDISON AVE
MODESTO CA
95350-5548
US

V. Phone/Fax

Practice location:
  • Phone: 209-576-1805
  • Fax:
Mailing address:
  • Phone: 209-544-0984
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: