Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2081S0010X | Sports Medicine | AT-0725 | MS |
Y | 213ES0000X | Sports Medicine | AT-0725 | MS |
NPI | 1104429620 |
---|---|
Provider Name | Christian Johnston |
First Address | Cleveland, MS 38732-3102 |
Second Address | Cleveland, MS 38733-0001 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 18/11/2020 |
Last Update Date | 18/11/2020 |