Provider Demographics
NPI:1639815616
Name:JOHNSON, THARON LOVELL
Entity Type:Individual
Prefix:
First Name:THARON
Middle Name:LOVELL
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 1:3414 SE TAURUS AVE
Mailing Address - Street 2:
Mailing Address - City:TOPEKA
Mailing Address - State:KS
Mailing Address - Zip Code:66605-1982
Mailing Address - Country:US
Mailing Address - Phone:785-207-2901
Mailing Address - Fax:
Practice Address - Street 1:3414 SE TAURUS AVE
Practice Address - Street 2:
Practice Address - City:TOPEKA
Practice Address - State:KS
Practice Address - Zip Code:66605-1982
Practice Address - Country:US
Practice Address - Phone:785-207-2901
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-11
Last Update Date:2022-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSK00407728343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)