Healthcare Provider Details

I. General information

NPI: 1851314785
Provider Name (Legal Business Name): DAVID MATTHEW JOHNSON MSPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 12/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

124 PETERSEN PARKWAY #6 SUITE 1
THAYNE WY
83127
US

IV. Provider business mailing address

124 PETERSEN PARKWAY #6
THAYNE WY
83127
US

V. Phone/Fax

Practice location:
  • Phone: 307-883-7878
  • Fax: 307-883-7877
Mailing address:
  • Phone: 307-883-9632
  • Fax: 307-883-7877

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1167
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: