Healthcare Provider Details

I. General information

NPI: 1922486307
Provider Name (Legal Business Name): AMY MAGNUSON DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2015
Last Update Date: 08/14/2024
Certification Date: 08/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2547 WI-35 STE #5
LUCK WI
54853
US

IV. Provider business mailing address

5366 386TH ST NE
NORTH BRANCH MN
55056-5833
US

V. Phone/Fax

Practice location:
  • Phone: 715-472-5225
  • Fax:
Mailing address:
  • Phone: 651-674-6775
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number4038
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number16135-24
License Number StateWI
# 3
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number10068
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: