MEDICARE: GWEN E JOHNSON MA, 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	:	1225166416
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GWEN E JOHNSON MA, ATC

Provider Business Mailing Address
First Line	:	5225 50TH AVE NE APT 103
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98105-2872
Country	:	US
Telephone Number	:	503-332-6706
Fax Number	:

Provider Business Practice Location Address
First Line	:	901 12TH AVE
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98122-4411
Country	:	US
Telephone Number	:	206-296-5452
Fax Number	:

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

Provider Enumeration Date	:	03/01/2007
Last Update Date	:	07/08/2007

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