Provider Demographics
NPI:1578865952
Name:JOHNSON, MEGAN PAMELA (PA-C)
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:PAMELA
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MEGAN
Other - Middle Name:PAMELA
Other - Last Name:KNAEBLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6405 FRANCE AVE S STE W400
Mailing Address - Street 2:
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-2165
Mailing Address - Country:US
Mailing Address - Phone:952-920-2730
Mailing Address - Fax:952-567-7090
Practice Address - Street 1:6405 FRANCE AVE S STE W400
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-2165
Practice Address - Country:US
Practice Address - Phone:952-920-2730
Practice Address - Fax:952-567-7090
Is Sole Proprietor?:No
Enumeration Date:2010-11-17
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1862363A00000X
IL085.003910363A00000X
MN11292363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNENROLLEDMedicaid
MNENROLLEDMedicaid