Provider Demographics
NPI:1528475092
Name:JOHNSON, SAMUEL (ATC)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 WOMENS BLDG
Mailing Address - Street 2:OREGON STATE UNIVERSITY
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97331-8577
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:101 WOMENS BLDG
Practice Address - Street 2:OREGON STATE UNIVERSITY
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97331-8577
Practice Address - Country:US
Practice Address - Phone:541-737-6801
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-16
Last Update Date:2014-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR101171342255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer