Provider Demographics
NPI:1285419358
Name:JOHNSON, PARKER (PT)
Entity type:Individual
Prefix:
First Name:PARKER
Middle Name:
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 1:4141 POLE LINE ROAD
Mailing Address - Street 2:STE A
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83202-4904
Mailing Address - Country:US
Mailing Address - Phone:208-242-8617
Mailing Address - Fax:833-608-2470
Practice Address - Street 1:4141 POLE LINE ROAD
Practice Address - Street 2:STE A
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83202-4904
Practice Address - Country:US
Practice Address - Phone:208-242-8617
Practice Address - Fax:833-608-2470
Is Sole Proprietor?:No
Enumeration Date:2023-08-28
Last Update Date:2024-08-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ID2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer