Provider Demographics
NPI:1558342105
Name:JOHNSON, WAYNE THOMAS (DC)
Entity Type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:THOMAS
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:70 S FAIRFIELD RD
Mailing Address - Street 2:SUITE 7
Mailing Address - City:LAYTON
Mailing Address - State:UT
Mailing Address - Zip Code:84041-5111
Mailing Address - Country:US
Mailing Address - Phone:801-444-1002
Mailing Address - Fax:801-444-0170
Practice Address - Street 1:70 S FAIRFIELD RD
Practice Address - Street 2:SUITE 7
Practice Address - City:LAYTON
Practice Address - State:UT
Practice Address - Zip Code:84041-5111
Practice Address - Country:US
Practice Address - Phone:801-444-1002
Practice Address - Fax:801-444-0170
Is Sole Proprietor?:No
Enumeration Date:2005-11-10
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT95-288007-1202111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTU53418Medicare UPIN
UT000056077Medicare ID - Type Unspecified