Provider Demographics
NPI:1851314785
Name:JOHNSON, DAVID MATTHEW (MSPT)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:MATTHEW
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 PETERSEN PARKWAY
Mailing Address - Street 2:#6
Mailing Address - City:THAYNE
Mailing Address - State:WY
Mailing Address - Zip Code:83127
Mailing Address - Country:US
Mailing Address - Phone:307-883-9632
Mailing Address - Fax:307-883-7877
Practice Address - Street 1:124 PETERSEN PARKWAY #6
Practice Address - Street 2:SUITE 1
Practice Address - City:THAYNE
Practice Address - State:WY
Practice Address - Zip Code:83127
Practice Address - Country:US
Practice Address - Phone:307-883-7878
Practice Address - Fax:307-883-7877
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2012-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY1167225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist