Provider Demographics
NPI:1124582051
Name:JOHNSON, MYLES ALEXANDER (EP-C)
Entity type:Individual
Prefix:
First Name:MYLES
Middle Name:ALEXANDER
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:EP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11420 SETHWARNER DR
Mailing Address - Street 2:
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23059-4802
Mailing Address - Country:US
Mailing Address - Phone:804-929-0405
Mailing Address - Fax:
Practice Address - Street 1:3600 W BROAD ST
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23230-4915
Practice Address - Country:US
Practice Address - Phone:804-585-6723
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-24
Last Update Date:2019-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA174H00000X
IN224Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Y00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersClinical Exercise Physiologist
No174H00000XOther Service ProvidersHealth Educator