Provider Demographics
NPI:1467773341
Name:JOHNSON, NATHAN RAY (LMT)
Entity Type:Individual
Prefix:MR
First Name:NATHAN
Middle Name:RAY
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2713 W SLIGH AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33614-4343
Mailing Address - Country:US
Mailing Address - Phone:813-935-4466
Mailing Address - Fax:813-935-0088
Practice Address - Street 1:2713 W SLIGH AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33614-4343
Practice Address - Country:US
Practice Address - Phone:813-935-4466
Practice Address - Fax:813-935-0088
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-15
Last Update Date:2010-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA 58953225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist