Provider Demographics
NPI:1043653033
Name:JOHNSON, WAYNE ANTHONY (RRT)
Entity Type:Individual
Prefix:MR
First Name:WAYNE
Middle Name:ANTHONY
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:RRT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 PLEASANT LAKES RDG
Mailing Address - Street 2:
Mailing Address - City:TERRY
Mailing Address - State:MS
Mailing Address - Zip Code:39170-8223
Mailing Address - Country:US
Mailing Address - Phone:601-506-3058
Mailing Address - Fax:
Practice Address - Street 1:205 PLEASANT LAKES RDG
Practice Address - Street 2:
Practice Address - City:TERRY
Practice Address - State:MS
Practice Address - Zip Code:39170-8223
Practice Address - Country:US
Practice Address - Phone:601-506-3058
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-10
Last Update Date:2013-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS16642279G1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2279G1100XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, RegisteredGeneral Care