Provider Demographics
NPI:1174062749
Name:WALSEMAN, JOHN
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:WALSEMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2505 MINNESOTA AVE NW APT 3
Mailing Address - Street 2:
Mailing Address - City:BEMIDJI
Mailing Address - State:MN
Mailing Address - Zip Code:56601-2474
Mailing Address - Country:US
Mailing Address - Phone:315-804-7047
Mailing Address - Fax:
Practice Address - Street 1:2505 MINNESOTA AVE NW APT 3
Practice Address - Street 2:
Practice Address - City:BEMIDJI
Practice Address - State:MN
Practice Address - Zip Code:56601-2474
Practice Address - Country:US
Practice Address - Phone:315-804-7047
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-15
Last Update Date:2017-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN492633247100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247100000XTechnologists, Technicians & Other Technical Service ProvidersRadiologic Technologist