Provider Demographics
NPI:1619926912
Name:GERGEN, JOHN A (PT, MBA)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:A
Last Name:GERGEN
Suffix:
Gender:M
Credentials:PT, MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:715 IONE AVE NE
Mailing Address - Street 2:
Mailing Address - City:SPRING LAKE PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55432-1240
Mailing Address - Country:US
Mailing Address - Phone:763-783-3552
Mailing Address - Fax:
Practice Address - Street 1:3111 124TH AVE NW
Practice Address - Street 2:SUITE 100
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433-4572
Practice Address - Country:US
Practice Address - Phone:763-236-8911
Practice Address - Fax:763-236-8930
Is Sole Proprietor?:No
Enumeration Date:2006-05-06
Last Update Date:2008-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN54772251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic