Healthcare Provider Details

I. General information

NPI: 1558909036
Provider Name (Legal Business Name): RYAN ANTHONY JOHNSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/16/2019
Last Update Date: 09/09/2026
Certification Date: 09/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

709 SPRING VALLEY RD
BURLINGTON WI
53105-7614
US

IV. Provider business mailing address

9512 S RYAN GREEN CT APT 9
FRANKLIN WI
53132-9593
US

V. Phone/Fax

Practice location:
  • Phone: 262-971-9300
  • Fax:
Mailing address:
  • Phone: 920-277-4119
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: