=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306701750
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BENJAMIN JONATHAN KROHN PTA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/18/2025
-----------------------------------------------------
Last Update Date | 12/18/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 430 MANOR DR
-----------------------------------------------------
City | SURING
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54174-9182
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-842-2191
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 608 W WALNUT DR
-----------------------------------------------------
City | STURGEON BAY
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54235-3064
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-842-2191
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | 4323-19
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------