Provider Demographics
NPI:1376135129
Name:JOHNSON, CARLY KRISTIN MARTHA (PA-C)
Entity type:Individual
Prefix:
First Name:CARLY
Middle Name:KRISTIN MARTHA
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2925 CHICAGO AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55407-1321
Mailing Address - Country:US
Mailing Address - Phone:612-262-9000
Mailing Address - Fax:
Practice Address - Street 1:7373 FRANCE AVE S STE 208
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-4598
Practice Address - Country:US
Practice Address - Phone:952-835-1311
Practice Address - Fax:952-428-0095
Is Sole Proprietor?:No
Enumeration Date:2021-02-03
Last Update Date:2025-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
MN14497363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant