Provider Demographics
NPI:1033584594
Name:CHRISTIANSON, JOHN IV (MED)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:
Last Name:CHRISTIANSON
Suffix:IV
Gender:M
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:725 CENTER AVE
Mailing Address - Street 2:SUITE 5
Mailing Address - City:MOORHEAD
Mailing Address - State:MN
Mailing Address - Zip Code:56560-1958
Mailing Address - Country:US
Mailing Address - Phone:218-287-1500
Mailing Address - Fax:218-287-1267
Practice Address - Street 1:725 CENTER AVE
Practice Address - Street 2:SUITE 5
Practice Address - City:MOORHEAD
Practice Address - State:MN
Practice Address - Zip Code:56560-1958
Practice Address - Country:US
Practice Address - Phone:218-287-1500
Practice Address - Fax:218-287-1267
Is Sole Proprietor?:No
Enumeration Date:2015-12-09
Last Update Date:2015-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN303778101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional