MEDICARE: KRISTINA R JOHNSON P.T.

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	208100000X	Physical Medicine & Rehabilitation Physician	7640	MN

General Provider Information

NPI Number	:	1053554113
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRISTINA R JOHNSON P.T.

Provider Business Mailing Address
First Line	:	3428 36TH AVE S
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55406-2704
Country	:	US
Telephone Number	:	612-501-7192
Fax Number	:

Provider Business Practice Location Address
First Line	:	3428 36TH AVE S
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55406-2704
Country	:	US
Telephone Number	:	612-501-7192
Fax Number	:

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

Provider Enumeration Date	:	04/19/2009
Last Update Date	:	04/19/2009

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