Provider Demographics
NPI:1376549436
Name:SWANSON, ANGIE RAE (MPT)
Entity Type:Individual
Prefix:MRS
First Name:ANGIE
Middle Name:RAE
Last Name:SWANSON
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4010 W 65TH ST
Mailing Address - Street 2:
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-1706
Mailing Address - Country:US
Mailing Address - Phone:952-456-7004
Mailing Address - Fax:952-456-7598
Practice Address - Street 1:4010 W 65TH ST
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-1706
Practice Address - Country:US
Practice Address - Phone:952-456-7004
Practice Address - Fax:952-456-7598
Is Sole Proprietor?:No
Enumeration Date:2005-06-23
Last Update Date:2012-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6331225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist