Provider Demographics
NPI:1356564520
Name:WAYNE A JOHANSEN
Entity type:Organization
Organization Name:WAYNE A JOHANSEN
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICAL THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:WAYNE
Authorized Official - Middle Name:A
Authorized Official - Last Name:JOHANSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-356-2334
Mailing Address - Street 1:PO BOX 31
Mailing Address - Street 2:
Mailing Address - City:BARABOO
Mailing Address - State:WI
Mailing Address - Zip Code:53913-0031
Mailing Address - Country:US
Mailing Address - Phone:608-356-2334
Mailing Address - Fax:608-356-2636
Practice Address - Street 1:626 14TH ST
Practice Address - Street 2:
Practice Address - City:BARABOO
Practice Address - State:WI
Practice Address - Zip Code:53913-1535
Practice Address - Country:US
Practice Address - Phone:608-356-2334
Practice Address - Fax:608-356-2636
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-10
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI987261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40414400Medicaid