Provider Demographics
NPI:1619676301
Name:JOHNSON, MORIAH (DPT)
Entity Type:Individual
Prefix:
First Name:MORIAH
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2310 PEGER RD STE 101
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99709-5305
Mailing Address - Country:US
Mailing Address - Phone:907-457-7678
Mailing Address - Fax:907-457-7677
Practice Address - Street 1:2310 PEGER RD STE 101
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99709-5305
Practice Address - Country:US
Practice Address - Phone:907-457-7678
Practice Address - Fax:907-457-7677
Is Sole Proprietor?:No
Enumeration Date:2023-03-01
Last Update Date:2024-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO204419225100000X
AK204419225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist