Provider Demographics
NPI:1316031206
Name:JOHNSON, THOMAS CHARLES JR (CRNP, BC)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:CHARLES
Last Name:JOHNSON
Suffix:JR
Gender:M
Credentials:CRNP, BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 N MONASTERY AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21229-3036
Mailing Address - Country:US
Mailing Address - Phone:410-945-9531
Mailing Address - Fax:
Practice Address - Street 1:333 WASHINGTON AVE N
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55401-1377
Practice Address - Country:US
Practice Address - Phone:443-562-9455
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2009-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR147881363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD082NS113Medicare PIN
MD003116M72Medicare PIN