MEDICARE: VIRGINIA JOHNSON RPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	611	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	6402665	OTHER	MN	MEDICA
2	7B190JO	OTHER	MN	BCBS
3	HP45781	OTHER	MN	HEALTH PARTNERS

General Provider Information

NPI Number	:	1053402842
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VIRGINIA JOHNSON RPT

Provider Business Mailing Address
First Line	:	24615 PRIMROSE LN
Second Line	:
City	:	LINDSTROM
State	:	MN
Zip	:	55045-9018
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	24615 PRIMROSE LN
Second Line	:
City	:	LINDSTROM
State	:	MN
Zip	:	55045-9018
Country	:	US
Telephone Number	:	763-689-5385
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/27/2006
Last Update Date	:	07/09/2007

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Directions to “ VIRGINIA JOHNSON RPT” Practice Location

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