Provider Demographics
NPI:1821615303
Name:JOHNSTON, NICHOLAS (DPT, PT, CSCS)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:JOHNSTON
Suffix:
Gender:M
Credentials:DPT, PT, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2818 E DARROW ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85042-6065
Mailing Address - Country:US
Mailing Address - Phone:530-410-5649
Mailing Address - Fax:
Practice Address - Street 1:4550 N BLACK CANYON HWY
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85017-3714
Practice Address - Country:US
Practice Address - Phone:602-995-2643
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-30
Last Update Date:2020-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPT-31312225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist