MEDICARE: MR. TYLER K JOHNSTON ATC, MS, LAT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer		HI

General Provider Information

NPI Number	:	1174012892
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. TYLER K JOHNSTON ATC, MS, LAT

Provider Business Mailing Address
First Line	:	3140 WAIALAE AVE
Second Line	:
City	:	HONOLULU
State	:	HI
Zip	:	96816-1578
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3140 WAIALAE AVE
Second Line	:
City	:	HONOLULU
State	:	HI
Zip	:	96816-1510
Country	:	US
Telephone Number	:	440-339-6722
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/08/2018
Last Update Date	:	05/08/2018

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