Provider Demographics
NPI:1376154708
Name:JOHNSON, CRAIG MATTHEW
Entity Type:Individual
Prefix:
First Name:CRAIG
Middle Name:MATTHEW
Last Name:JOHNSON
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 1:8103 UPPER 129TH CT
Mailing Address - Street 2:
Mailing Address - City:APPLE VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55124-6283
Mailing Address - Country:US
Mailing Address - Phone:612-282-8286
Mailing Address - Fax:
Practice Address - Street 1:8103 UPPER 129TH CT
Practice Address - Street 2:
Practice Address - City:APPLE VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55124-6283
Practice Address - Country:US
Practice Address - Phone:612-282-8286
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-10
Last Update Date:2020-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNBC629235171WH0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171WH0202XOther Service ProvidersContractorHome Modifications