Provider Demographics
NPI:1538611280
Name:JOHNSON, SHAY (DPT)
Entity type:Individual
Prefix:MR
First Name:SHAY
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5190 GOVERNOR DR. SUITE 107
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92122
Mailing Address - Country:US
Mailing Address - Phone:858-452-0282
Mailing Address - Fax:
Practice Address - Street 1:5190 GOVERNOR DR STE 107
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92122-2848
Practice Address - Country:US
Practice Address - Phone:858-452-0282
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-28
Last Update Date:2016-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 2922162251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic