Provider Demographics
NPI:1538260567
Name:HOFIUS, JAMES GORDON (MPT)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:GORDON
Last Name:HOFIUS
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3165 FERNBROOK LN N
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55447-5320
Mailing Address - Country:US
Mailing Address - Phone:763-710-4637
Mailing Address - Fax:
Practice Address - Street 1:3165 FERNBROOK LN N
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55447-5320
Practice Address - Country:US
Practice Address - Phone:763-497-1153
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2019-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN11052225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWPT29190AOtherP.T. LICENSE
CAWPT29190AOtherP.T. LICENSE
CAQ12627Medicare UPIN