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 1:15856 LINNET ST NW
Mailing Address - Street 2:
Mailing Address - City:ANDOVER
Mailing Address - State:MN
Mailing Address - Zip Code:55304-2686
Mailing Address - Country:US
Mailing Address - Phone:763-221-1424
Mailing Address - Fax:
Practice Address - Street 1:19131 TAYLOR ST NE
Practice Address - Street 2:
Practice Address - City:EAST BETHEL
Practice Address - State:MN
Practice Address - Zip Code:55011-4422
Practice Address - Country:US
Practice Address - Phone:763-392-5443
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-06
Last Update Date:2025-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5477225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN049509300Medicaid