Provider Demographics
NPI:1851745327
Name:JOHNSON, IAN (LAC)
Entity Type:Individual
Prefix:
First Name:IAN
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 UNIVERSITY AVE W
Mailing Address - Street 2:6TH FLOOR
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-3727
Mailing Address - Country:US
Mailing Address - Phone:651-232-2273
Mailing Address - Fax:651-232-4953
Practice Address - Street 1:1700 UNIVERSITY AVE W
Practice Address - Street 2:6TH FLOOR
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-3727
Practice Address - Country:US
Practice Address - Phone:651-232-2273
Practice Address - Fax:651-232-4953
Is Sole Proprietor?:No
Enumeration Date:2016-04-20
Last Update Date:2016-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1375171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist