Provider Demographics
NPI:1346257797
Name:JOHNSON, QUENTIN HEATH (PT)
Entity Type:Individual
Prefix:MR
First Name:QUENTIN
Middle Name:HEATH
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3530 W MINERAL KING AVE
Mailing Address - Street 2:SUITE D
Mailing Address - City:NISALIA
Mailing Address - State:CA
Mailing Address - Zip Code:93291
Mailing Address - Country:US
Mailing Address - Phone:559-625-2777
Mailing Address - Fax:559-625-3373
Practice Address - Street 1:3530 W MINERAL KING AVE
Practice Address - Street 2:SUITE D
Practice Address - City:NISALIA
Practice Address - State:CA
Practice Address - Zip Code:93291
Practice Address - Country:US
Practice Address - Phone:559-625-2777
Practice Address - Fax:559-625-3373
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT23021225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q07550Medicare UPIN
OPT230210Medicare PIN