Provider Demographics
NPI:1124396619
Name:JOHNSON, ERIC MARSHALL (PT TECH)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:MARSHALL
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PT TECH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:LYSTER ARMY HEALTH CLINIC
Mailing Address - Street 2:BLDG 301
Mailing Address - City:FORT RUCKER
Mailing Address - State:AL
Mailing Address - Zip Code:36362-5333
Mailing Address - Country:US
Mailing Address - Phone:334-255-7169
Mailing Address - Fax:334-255-7368
Practice Address - Street 1:LYSTER ARMY HEALTH CLINIC
Practice Address - Street 2:BLDG 301
Practice Address - City:FORT RUCKER
Practice Address - State:AL
Practice Address - Zip Code:36362-5333
Practice Address - Country:US
Practice Address - Phone:334-255-7169
Practice Address - Fax:334-255-7368
Is Sole Proprietor?:No
Enumeration Date:2011-12-12
Last Update Date:2011-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXB1948957146N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, Basic