Provider Demographics
NPI:1023206935
Name:JOHNSON, TAMARA A (PA-C)
Entity Type:Individual
Prefix:
First Name:TAMARA
Middle Name:A
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:TAMARA
Other - Middle Name:A
Other - Last Name:SKALSH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:6465 WAYZATA BLVD
Mailing Address - Street 2:STE 210
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55426-1728
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6490 EXCELSIOR BLVD
Practice Address - Street 2:STE W200
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55426-4705
Practice Address - Country:US
Practice Address - Phone:952-993-3180
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-05
Last Update Date:2007-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1045363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant