Healthcare Provider Details

I. General information

NPI: 1699959320
Provider Name (Legal Business Name): PAUL-WAYNE JOHNSON MAHLOW MA, ATC, CSCS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/17/2007
Last Update Date: 12/17/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

455 OCONNOR DR SUITE 150
SAN JOSE CA
95128-1633
US

IV. Provider business mailing address

455 OCONNOR DR SUITE 150
SAN JOSE CA
95128-1633
US

V. Phone/Fax

Practice location:
  • Phone: 408-293-7767
  • Fax: 408-294-6595
Mailing address:
  • Phone: 408-293-7767
  • Fax: 408-294-6595

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: