Healthcare Provider Details

I. General information

NPI: 1053901983
Provider Name (Legal Business Name): ANDREW SCOTT JOHNSON PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/25/2021
Last Update Date: 01/25/2021
Certification Date: 01/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

240 HOSPITAL DR NE
BOLIVIA NC
28422-8346
US

IV. Provider business mailing address

2216 FRANKLIN CIR
LITTLE RIVER SC
29566-9119
US

V. Phone/Fax

Practice location:
  • Phone: 910-721-1000
  • Fax:
Mailing address:
  • Phone: 828-292-4393
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2933
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: