Healthcare Provider Details

I. General information

NPI: 1386375558
Provider Name (Legal Business Name): TRACY JOHNSON DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: GUS JOHNSON DPT

II. Dates (important events)

Enumeration Date: 06/20/2022
Last Update Date: 11/22/2024
Certification Date: 11/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5301 LONGLEY LN UNIT C
RENO NV
89511-1805
US

IV. Provider business mailing address

209 KIRKLAND AVE
KIRKLAND WA
98033-6503
US

V. Phone/Fax

Practice location:
  • Phone: 916-905-6378
  • Fax: 916-672-0114
Mailing address:
  • Phone: 425-629-3502
  • Fax: 425-629-3517

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT61311447
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number304342
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number6518
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: