MEDICARE: WAYNE A JOHANSEN PT

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
1	225100000X	Physical Therapist	987	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1028602	OTHER	WI	PHYSICIANS PLUS INS CORP
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	W006005	OTHER	WI	CHAMPUS
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	39-1598907-01	OTHER	WI	UNITY HEALTH INSUR

General Provider Information

NPI Number	:	1629064126
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WAYNE A JOHANSEN PT

Provider Business Mailing Address
First Line	:	PO BOX 31
Second Line	:
City	:	BARABOO
State	:	WI
Zip	:	53913-0031
Country	:	US
Telephone Number	:	608-356-2334
Fax Number	:	608-356-2636

Provider Business Practice Location Address
First Line	:	626 14TH ST
Second Line	:
City	:	BARABOO
State	:	WI
Zip	:	53913-1535
Country	:	US
Telephone Number	:	608-356-2334
Fax Number	:	608-356-2636

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/21/2005
Last Update Date	:	07/09/2007

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Directions to “ WAYNE A JOHANSEN PT” Practice Location

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