Provider Demographics
NPI:1043756414
Name:JOHNSON, KENNETH BYRON (PHYSICAL THERAPIST)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:BYRON
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PHYSICAL THERAPIST
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 921103
Mailing Address - Street 2:
Mailing Address - City:DUTCH HARBOR
Mailing Address - State:AK
Mailing Address - Zip Code:99692-1103
Mailing Address - Country:US
Mailing Address - Phone:907-359-3585
Mailing Address - Fax:
Practice Address - Street 1:36 LAVELLE COURT
Practice Address - Street 2:
Practice Address - City:UNALASKA
Practice Address - State:AK
Practice Address - Zip Code:99685
Practice Address - Country:US
Practice Address - Phone:907-581-1202
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-10
Last Update Date:2017-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKPHYP2225225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist