Healthcare Provider Details

I. General information

NPI: 1669229142
Provider Name (Legal Business Name): JOSHUA JUAIRE PT, DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/02/2024
Last Update Date: 05/23/2024
Certification Date: 05/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1939 MINNEHAHA AVE W STE 100
SAINT PAUL MN
55104-1033
US

IV. Provider business mailing address

1939 MINNEHAHA AVE W STE 300
SAINT PAUL MN
55104-1033
US

V. Phone/Fax

Practice location:
  • Phone: 651-348-7428
  • Fax: 651-348-7432
Mailing address:
  • Phone: 651-748-4338
  • Fax: 651-748-2892

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number13464
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: