Provider Demographics
NPI:1942649850
Name:JOHANSON, LUKE A (FNP)
Entity Type:Individual
Prefix:MR
First Name:LUKE
Middle Name:A
Last Name:JOHANSON
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 22ND AVE
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:WI
Mailing Address - Zip Code:53566-1569
Mailing Address - Country:US
Mailing Address - Phone:740-333-2234
Mailing Address - Fax:740-333-3881
Practice Address - Street 1:515 22ND AVENUE
Practice Address - Street 2:MONROE CLINIC
Practice Address - City:MONROE
Practice Address - State:WI
Practice Address - Zip Code:53566-1569
Practice Address - Country:US
Practice Address - Phone:608-324-2222
Practice Address - Fax:740-333-5171
Is Sole Proprietor?:No
Enumeration Date:2013-06-25
Last Update Date:2020-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH14520.NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0098667Medicaid
OHH288920Medicare PIN