Provider Demographics
NPI:1275617128
Name:SAMUELSON, JOHN WAYNE (DC)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:WAYNE
Last Name:SAMUELSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13 W 2ND AVE N
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:MN
Mailing Address - Zip Code:55705-1313
Mailing Address - Country:US
Mailing Address - Phone:218-229-3638
Mailing Address - Fax:218-229-2661
Practice Address - Street 1:13 W 2ND AVE N
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:MN
Practice Address - Zip Code:55705-1313
Practice Address - Country:US
Practice Address - Phone:218-229-3638
Practice Address - Fax:218-229-2661
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1626111NX0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NX0800XChiropractic ProvidersChiropractorOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN69716SAOtherBLUE CROSS BLUE SHIELD
MN230743OtherCHIROCARE
MN69716SAOtherBLUE CROSS BLUE SHIELD