Provider Demographics
NPI:1760723159
Name:JOHNSON, FREDERICK L (PTA)
Entity Type:Individual
Prefix:
First Name:FREDERICK
Middle Name:L
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3201 SE PISCES AVE
Mailing Address - Street 2:
Mailing Address - City:TOPEKA
Mailing Address - State:KS
Mailing Address - Zip Code:66605-1831
Mailing Address - Country:US
Mailing Address - Phone:785-274-3337
Mailing Address - Fax:785-266-5782
Practice Address - Street 1:1205 SW 29TH ST
Practice Address - Street 2:
Practice Address - City:TOPEKA
Practice Address - State:KS
Practice Address - Zip Code:66611-1203
Practice Address - Country:US
Practice Address - Phone:785-274-3337
Practice Address - Fax:785-266-5782
Is Sole Proprietor?:No
Enumeration Date:2013-03-08
Last Update Date:2013-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS14-02284225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS225200000XOtherNPI