Provider Demographics
NPI:1013454180
Name:JOHNSON, JOE DOUGLAS (PTA)
Entity Type:Individual
Prefix:
First Name:JOE
Middle Name:DOUGLAS
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 1:180 QUARTERHORSE CIR
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89508-9511
Mailing Address - Country:US
Mailing Address - Phone:775-313-5556
Mailing Address - Fax:
Practice Address - Street 1:3101 PLUMAS ST
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89509-4515
Practice Address - Country:US
Practice Address - Phone:775-829-7220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-26
Last Update Date:2017-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVA-0418225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant