Provider Demographics
NPI:1437590882
Name:JOHNSON, NATHAN DALE (DO)
Entity Type:Individual
Prefix:DR
First Name:NATHAN
Middle Name:DALE
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1510
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54702-1510
Mailing Address - Country:US
Mailing Address - Phone:608-785-0940
Mailing Address - Fax:
Practice Address - Street 1:800 WEST AVE S
Practice Address - Street 2:
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54601
Practice Address - Country:US
Practice Address - Phone:608-785-0940
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-15
Last Update Date:2020-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN66084207X00000X
WI71635207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery