MEDICARE: BRANDON JOHNSON ATC

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

General Provider Information

NPI Number	:	1205359114
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRANDON JOHNSON ATC

Provider Business Mailing Address
First Line	:	4343 E SOLIERE AVE APT 1050
Second Line	:
City	:	FLAGSTAFF
State	:	AZ
Zip	:	86004-7947
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1705 N SAN FRANCISCO ST
Second Line	:
City	:	FLAGSTAFF
State	:	AZ
Zip	:	86001-1348
Country	:	US
Telephone Number	:	702-606-7241
Fax Number	:

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

Provider Enumeration Date	:	07/23/2017
Last Update Date	:	07/23/2017

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