Provider Demographics
NPI:1205898228
Name:JOHNSON, MICHAEL D (MA, APRN, CRNP)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:D
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MA, APRN, CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 43
Mailing Address - Street 2:MR 10809
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55440-0043
Mailing Address - Country:US
Mailing Address - Phone:612-262-4813
Mailing Address - Fax:612-262-4194
Practice Address - Street 1:5300 ALPINE DR NW
Practice Address - Street 2:
Practice Address - City:RAMSEY
Practice Address - State:MN
Practice Address - Zip Code:55303-4778
Practice Address - Country:US
Practice Address - Phone:763-236-0000
Practice Address - Fax:763-236-0025
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR1236271207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
S77388Medicare UPIN