Healthcare Provider Details

I. General information

NPI: 1366950347
Provider Name (Legal Business Name): BRANDON JOHNSON DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/12/2018
Last Update Date: 01/16/2020
Certification Date: 01/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9328 OUTER BANKS AVE
LAS VEGAS NV
89149-0195
US

IV. Provider business mailing address

9328 OUTER BANKS AVE
LAS VEGAS NV
89149-0195
US

V. Phone/Fax

Practice location:
  • Phone: 858-525-2832
  • Fax:
Mailing address:
  • Phone: 858-525-2832
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251G0304X
TaxonomyGeriatric Physical Therapist
License Number4113
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code2251N0400X
TaxonomyNeurology Physical Therapist
License Number4113
License Number StateNV
# 3
Primary TaxonomyN
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number4113
License Number StateNV
# 4
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number4113
License Number StateNV
# 5
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: