Healthcare Provider Details

I. General information

NPI: 1821429135
Provider Name (Legal Business Name): MATTHEW JAMES JOHNSON PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/12/2013
Last Update Date: 12/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 H ST
FAIRBURY NE
68352-1119
US

IV. Provider business mailing address

3106 TRADERS POINTE RD
COUNCIL BLUFFS IA
51501-8547
US

V. Phone/Fax

Practice location:
  • Phone: 402-729-3351
  • Fax:
Mailing address:
  • Phone: 712-329-0853
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number1257
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: