Healthcare Provider Details

I. General information

NPI: 1205971611
Provider Name (Legal Business Name): MATTHEW JOHN JOHNSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/21/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 UNIVERSITY AVE W STE 160
SAINT PAUL MN
55114-1841
US

IV. Provider business mailing address

20599 HAMPSHIRE WAY
LAKEVILLE MN
55044-4671
US

V. Phone/Fax

Practice location:
  • Phone: 651-917-3634
  • Fax: 651-917-3620
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: