Healthcare Provider Details

I. General information

NPI: 1679579429
Provider Name (Legal Business Name): RICHARD E JOHNSON P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/27/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 E 1ST ST STE 400
DULUTH MN
55805-2297
US

IV. Provider business mailing address

1000 E 1ST ST STE 400
DULUTH MN
55805-2297
US

V. Phone/Fax

Practice location:
  • Phone: 218-722-5513
  • Fax: 218-722-6515
Mailing address:
  • Phone: 218-722-5513
  • Fax: 218-722-6515

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number8860
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: