=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912899105
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOHNSON EMMANUEL
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/21/2025
-----------------------------------------------------
Last Update Date | 07/21/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8150 PINES BLVD
-----------------------------------------------------
City | PEMBROKE PINES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33024-6710
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 754-208-3765
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2843 SW 179TH TER
-----------------------------------------------------
City | MIRAMAR
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33029-5165
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-213-5209
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | PTA32421
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------