Provider Demographics
NPI:1881069862
Name:JOHNSON, THOMAS MARK (RN)
Entity type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:MARK
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N5733 GURHOLT LAKE RD
Mailing Address - Street 2:
Mailing Address - City:SCANDINAVIA
Mailing Address - State:WI
Mailing Address - Zip Code:54977-9736
Mailing Address - Country:US
Mailing Address - Phone:715-467-2324
Mailing Address - Fax:
Practice Address - Street 1:N5733 GURHOLT LAKE RD
Practice Address - Street 2:
Practice Address - City:SCANDINAVIA
Practice Address - State:WI
Practice Address - Zip Code:54977-9736
Practice Address - Country:US
Practice Address - Phone:715-467-2324
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-02
Last Update Date:2015-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI69342-30163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice