Healthcare Provider Details

I. General information

NPI: 1760308167
Provider Name (Legal Business Name): BO JOHANNES RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2026
Last Update Date: 06/29/2026
Certification Date: 06/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9300 HENNEPIN TOWN RD STE 110
EDEN PRAIRIE MN
55347-3072
US

IV. Provider business mailing address

9300 HENNEPIN TOWN RD STE 110
EDEN PRAIRIE MN
55347-3072
US

V. Phone/Fax

Practice location:
  • Phone: 651-280-8774
  • Fax: 844-479-8458
Mailing address:
  • Phone: 651-280-8774
  • Fax: 844-479-8458

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number2484148
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: