Basic Information
| Provider Information | |||||||||
| NPI: | 1043756414 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | BYRON | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PHYSICAL THERAPIST | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 921103 | ||||||||
| Address2: | |||||||||
| City: | DUTCH HARBOR | ||||||||
| State: | AK | ||||||||
| PostalCode: | 996921103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9073593585 | ||||||||
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| Practice Location | |||||||||
| Address1: | 36 LAVELLE COURT | ||||||||
| Address2: | |||||||||
| City: | UNALASKA | ||||||||
| State: | AK | ||||||||
| PostalCode: | 99685 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9075811202 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/10/2017 | ||||||||
| LastUpdateDate: | 01/10/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PHYP2225 | AK | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.