Provider Demographics
NPI:1710190939
Name:JOHNSON, PATRICK KELLY (MD)
Entity Type:Individual
Prefix:DR
First Name:PATRICK
Middle Name:KELLY
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:3790 COON RAPIDS BLVD NW
Mailing Address - Street 2:
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55433-2629
Mailing Address - Country:US
Mailing Address - Phone:763-421-7420
Mailing Address - Fax:763-421-0730
Practice Address - Street 1:3790 COON RAPIDS BLVD NW
Practice Address - Street 2:
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433-2629
Practice Address - Country:US
Practice Address - Phone:763-421-7420
Practice Address - Fax:763-421-0730
Is Sole Proprietor?:No
Enumeration Date:2007-05-07
Last Update Date:2012-05-10
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MN102991207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1157570002Medicare NSC
MN1157570001Medicare NSC