Provider Demographics
NPI:1508455841
Name:JOHNSON, BRANDON (ATC)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2429 5TH ST N
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:MS
Mailing Address - Zip Code:39705-2005
Mailing Address - Country:US
Mailing Address - Phone:662-328-4542
Mailing Address - Fax:
Practice Address - Street 1:2429 5TH ST N
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:MS
Practice Address - Zip Code:39705-2005
Practice Address - Country:US
Practice Address - Phone:662-328-4542
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-12
Last Update Date:2021-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSAT03052255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
110202022OtherATHLETIC TRAINER LICENSE NUMBER