Provider Demographics
NPI:1851466411
Name:JOHNSEN, IAN ALAN (MSPT)
Entity type:Individual
Prefix:MR
First Name:IAN
Middle Name:ALAN
Last Name:JOHNSEN
Suffix:
Gender:M
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2110 116TH AVE NE
Mailing Address - Street 2:SUITE D
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98004
Mailing Address - Country:US
Mailing Address - Phone:206-734-9033
Mailing Address - Fax:425-449-8298
Practice Address - Street 1:2110 116TH AVE NE
Practice Address - Street 2:SUITE D
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004
Practice Address - Country:US
Practice Address - Phone:206-734-9033
Practice Address - Fax:425-449-8298
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-21
Last Update Date:2015-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT000091082251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8879643Medicare UPIN