Provider Demographics
NPI:1518721943
Name:JOHNSON, EVAN
Entity Type:Individual
Prefix:
First Name:EVAN
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8800 HIGHWAY 290 W APT 517
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78736-7861
Mailing Address - Country:US
Mailing Address - Phone:612-799-4568
Mailing Address - Fax:
Practice Address - Street 1:3901 S LAMAR BLVD STE 140
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78704-7989
Practice Address - Country:US
Practice Address - Phone:512-462-3275
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-07
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty