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NPI Code Detail

MEDICARE: ANNA JOHNSON ATC

MEDICARE: ANNA JOHNSON ATC
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
12255A2300XAthletic Trainer1864MN

General Provider Information

NPI Number : 1760402879
Entity Type Code : Individual
Provider Name (Legal Business Name) : ANNA JOHNSON ATC
Provider Business Mailing Address
First Line : 730 10TH ST NW APT 7
Second Line :
City : NEW BRIGHTON
State : MN
Zip : 55112-6724
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 11725 STINSON AVE
Second Line :
City : CHISAGO CITY
State : MN
Zip : 55013-9542
Country : US
Telephone Number : 651-257-8469
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/20/2006
Last Update Date : 07/08/2007

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