Provider Demographics
NPI:1770806374
Name:JOHNSON, KEVIN NEIL (PT,ATC)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:NEIL
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PT,ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9913 214TH ST W STE B
Mailing Address - Street 2:
Mailing Address - City:LAKEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55044-1914
Mailing Address - Country:US
Mailing Address - Phone:952-985-2020
Mailing Address - Fax:
Practice Address - Street 1:9913 214TH ST W STE B
Practice Address - Street 2:
Practice Address - City:LAKEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55044-1914
Practice Address - Country:US
Practice Address - Phone:952-985-2020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-10
Last Update Date:2010-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN49012081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine