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General NPI Number Information
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NPI Number | 1154888006
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Entity Type | Individual
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Provider Name | FRED ALLEN JOHNSON PTA
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Gender | Male
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Dates
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Enumeration Date | 02/27/2019
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Last Update Date | 02/27/2019
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Provider Practice Location Address
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Address Line | 140 BRIMLEY DR
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City | FREDERICKSBURG
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State | VA
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Zip | 22406-5103
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Country | US
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Telephone | 540-752-0001
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Fax |
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Provider Business Mailing Address
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Address Line | 1 KING GEORGE CV
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City | RUTHER GLEN
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State | VA
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Zip | 22546-5132
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Country | US
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Telephone | 804-448-9618
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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 | 225200000X
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Taxonomy Name | Physical Therapy Assistant
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License Number | 23O6603133
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License Number State | VA
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