Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 225100000X | Physical Therapist | PT00005729 | WA |
Y | 2251H1200X | Hand | PT00005729 | WA |
NPI | 1962579375 |
---|---|
Provider Name | Mr. Clyde W Johnson |
First Address | Issaquah, WA 98029-5436 |
Second Address | Bellevue, WA 98004 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 29/11/2006 |
Last Update Date | 12/09/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1023366 | (05) | WA |