MEDICARE: MATTHEW JOHN JOHNSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3747P1801X	Personal Care Attendant

General Provider Information

NPI Number	:	1205971611
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MATTHEW JOHN JOHNSON

Provider Business Mailing Address
First Line	:	20599 HAMPSHIRE WAY
Second Line	:
City	:	LAKEVILLE
State	:	MN
Zip	:	55044-4671
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2200 UNIVERSITY AVE W STE 160
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55114-1841
Country	:	US
Telephone Number	:	651-917-3634
Fax Number	:	651-917-3620

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/21/2007
Last Update Date	:	07/08/2007

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