Healthcare Provider Details

I. General information

NPI: 1629064126
Provider Name (Legal Business Name): WAYNE A JOHANSEN PT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/21/2005
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

626 14TH ST
BARABOO WI
53913-1535
US

IV. Provider business mailing address

PO BOX 31
BARABOO WI
53913-0031
US

V. Phone/Fax

Practice location:
  • Phone: 608-356-2334
  • Fax: 608-356-2636
Mailing address:
  • Phone: 608-356-2334
  • Fax: 608-356-2636

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number987
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: