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General NPI Number Information
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NPI Number | 1003575747
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Entity Type | Individual
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Provider Name | BRUCE JOHNSTON
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Gender | Male
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Dates
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Enumeration Date | 12/09/2021
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Last Update Date | 12/09/2021
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Provider Practice Location Address
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Address Line | 2000 TRIDENT WAY
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City | SAN DIEGO
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State | CA
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Zip | 92155-5599
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Country | US
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Telephone | 513-641-6644
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Fax |
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Provider Business Mailing Address
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Address Line | 3398 N SIERRA SPRINGS DR
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City | TUCSON
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State | AZ
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Zip | 85712-6671
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | ATR-001165
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License Number State | AZ
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