Healthcare Provider Details

I. General information

NPI: 1346739877
Provider Name (Legal Business Name): GREGORY WAYNE JOHNSON NP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/10/2018
Last Update Date: 09/23/2020
Certification Date: 09/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9900 BREN RD E
MINNETONKA MN
55343-9664
US

IV. Provider business mailing address

465 LAKE LAUREL RD NE
MILLEDGEVILLE GA
31061-8447
US

V. Phone/Fax

Practice location:
  • Phone: 478-234-7849
  • Fax:
Mailing address:
  • Phone: 470-222-8194
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN202149
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: