Provider Demographics
NPI:1043635501
Name:JOHNSON, NICHOLAS ROBERT (PT, DPT)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:ROBERT
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1790
Mailing Address - Street 2:
Mailing Address - City:DOUGLAS
Mailing Address - State:WY
Mailing Address - Zip Code:82633-1790
Mailing Address - Country:US
Mailing Address - Phone:307-358-9464
Mailing Address - Fax:307-358-9330
Practice Address - Street 1:1900 CONVERSE AVE STE B
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-4112
Practice Address - Country:US
Practice Address - Phone:307-514-2411
Practice Address - Fax:307-514-2392
Is Sole Proprietor?:No
Enumeration Date:2014-02-20
Last Update Date:2019-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS11-04736225100000X
WY1858225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
890608OtherOPTUM
50464025OtherBCBS-KC
KYKA2868069OtherMEDICARE PTAN
KSUSES NPIOtherBCBS-KANSAS