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General NPI Number Information
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NPI Number | 1265143093
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Entity Type | Individual
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Provider Name | MICHAEL SOUSA-JOHNSON MS, LAT, ATC
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Gender | Male
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Dates
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Enumeration Date | 12/13/2022
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Last Update Date | 12/13/2022
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Provider Practice Location Address
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Address Line | 502 E LAMAR ALEXANDER PKWY
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City | MARYVILLE
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State | TN
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Zip | 37804-5919
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Country | US
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Telephone | 209-535-5176
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Fax |
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Provider Business Mailing Address
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Address Line | 214 JUNIPER AVE
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City | ALCOA
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State | TN
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Zip | 37701-2828
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Country | US
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Telephone | 209-535-5176
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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 | 2972
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License Number State | TN
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