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NPI Code Detail

MEDICARE: MR. PAUL T JOHNSON

MEDICARE: MR. PAUL T JOHNSON
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
1225100000XPhysical TherapistPT12496CA

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1ZZZ64164ZOTHERCABLUESHIELD

General Provider Information

NPI Number : 1720208317
Entity Type Code : Individual
Provider Name (Legal Business Name) : MR. PAUL T JOHNSON
Provider Business Mailing Address
First Line : 3033 CLEVELAND AVE
Second Line : 205
City : SANTA ROSA
State : CA
Zip : 95403-2126
Country : US
Telephone Number : 707-542-8313
Fax Number :
Provider Business Practice Location Address
First Line : 3033 CLEVELAND AVE
Second Line : 205
City : SANTA ROSA
State : CA
Zip : 95403-2126
Country : US
Telephone Number : 707-542-8313
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 04/26/2007
Last Update Date : 07/08/2007

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