Provider Demographics
NPI:1013945120
Name:JOHNSON, MITCHELL TROY (PT)
Entity Type:Individual
Prefix:
First Name:MITCHELL
Middle Name:TROY
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2002 W SUNSET DR
Mailing Address - Street 2:SUITE NUMBER 1
Mailing Address - City:RIVERTON
Mailing Address - State:WY
Mailing Address - Zip Code:82501-2283
Mailing Address - Country:US
Mailing Address - Phone:307-856-7021
Mailing Address - Fax:307-856-5546
Practice Address - Street 1:2002 W SUNSET DR
Practice Address - Street 2:SUITE NUMBER 1
Practice Address - City:RIVERTON
Practice Address - State:WY
Practice Address - Zip Code:82501-2283
Practice Address - Country:US
Practice Address - Phone:307-856-7021
Practice Address - Fax:307-856-5546
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2007-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYPT-1207225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY315547OtherBLUE CROSS BLUE SHIELD
CAOPT284891Medicare ID - Type UnspecifiedMEDICARE NUMBER
Q06166Medicare UPIN
WYW21449Medicare PIN