Provider Demographics
NPI:1922732452
Name:JOHNSON, IAN MARK (PA-C)
Entity Type:Individual
Prefix:
First Name:IAN
Middle Name:MARK
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1950 NORTHWESTERN AVE S STE 102
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:MN
Mailing Address - Zip Code:55082-7615
Mailing Address - Country:US
Mailing Address - Phone:651-430-3800
Mailing Address - Fax:
Practice Address - Street 1:7373 FRANCE AVE S STE 408
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-4549
Practice Address - Country:US
Practice Address - Phone:651-430-3800
Practice Address - Fax:651-430-3827
Is Sole Proprietor?:No
Enumeration Date:2022-07-11
Last Update Date:2023-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN14703363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant