Provider Demographics
NPI:1609051168
Name:JOHNSON, THOMAS III (APRN, CNP)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:JOHNSON
Suffix:III
Gender:M
Credentials:APRN, CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:516 S POKEGAMA AVE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55744-3820
Mailing Address - Country:US
Mailing Address - Phone:218-302-4468
Mailing Address - Fax:218-302-1457
Practice Address - Street 1:516 S POKEGAMA AVE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55744-3820
Practice Address - Country:US
Practice Address - Phone:218-327-2001
Practice Address - Fax:218-302-1457
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-03
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR 179591-6163W00000X
MN2950363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
No163W00000XNursing Service ProvidersRegistered Nurse