Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225100000X | Physical Therapist | 0165 | SD |
N | 225100000X | Physical Therapist | 2909 | MN |
N | 225100000X | Physical Therapist | 3511 | IA |
NPI | 1003093683 |
---|---|
Provider Name | Mr. Glenn A. Johnson |
First Address | Sioux Falls, SD 57108-4646 |
Second Address | Sioux Falls, SD 57108-4646 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 26/01/2008 |
Last Update Date | 26/01/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
5830370 | (05) | SD |