1063012193 NPI number — TIFFANY MONIQUE JOHNSON PTA

Table of content: (NPI 1497797229)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063012193 NPI number — TIFFANY MONIQUE JOHNSON PTA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JOHNSON
Provider First Name:
TIFFANY
Provider Middle Name:
MONIQUE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PTA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063012193
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/28/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
149 HIGH OAK
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
UNIVERSAL CITY
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78148-3705
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
210-995-6790
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
19138 US HIGHWAY 281 N STE 200
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN ANTONIO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78258-4988
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-489-7270
Provider Business Practice Location Address Fax Number:
210-403-2425
Provider Enumeration Date:
10/28/2020

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225200000X , with the licence number:  2071599 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2071599 . This is a "TEXAS BOARD OF PHYSICAL THERAPY EXAMINERS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".