Provider Demographics
NPI:1396052247
Name:JOHNSON, TYRONE
Entity type:Individual
Prefix:
First Name:TYRONE
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4242 PINEFIELD CT
Mailing Address - Street 2:
Mailing Address - City:RANDALLSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21133-5315
Mailing Address - Country:US
Mailing Address - Phone:443-813-1555
Mailing Address - Fax:
Practice Address - Street 1:4242 PINEFIELD CT
Practice Address - Street 2:
Practice Address - City:RANDALLSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21133-5315
Practice Address - Country:US
Practice Address - Phone:443-813-1555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-13
Last Update Date:2010-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD225200000X225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDA3356OtherPTA