1629064126 NPI number — WAYNE A JOHANSEN PT

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629064126 NPI number — WAYNE A JOHANSEN PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JOHANSEN
Provider First Name:
WAYNE
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1629064126
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

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

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
626 14TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BARABOO
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53913-1535
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
608-356-2334
Provider Business Practice Location Address Fax Number:
608-356-2636
Provider Enumeration Date:
09/21/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  987 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1028602 . This is a "PHYSICIANS PLUS INS CORP" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 40414400 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: W006005 . This is a "CHAMPUS" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 40119700 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 39-1598907-01 . This is a "UNITY HEALTH INSUR" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".




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