Healthcare Provider Details

I. General information

NPI: 1750650552
Provider Name (Legal Business Name): WILLIAM D JOHNSON PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/22/2011
Last Update Date: 12/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 E H ST
IRON MOUNTAIN MI
49801-4760
US

IV. Provider business mailing address

W9400-5 PETERSON DR
IRON MOUNTAIN MI
49801-9545
US

V. Phone/Fax

Practice location:
  • Phone: 906-774-3300
  • Fax:
Mailing address:
  • Phone: 906-221-0626
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number96119
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: