Healthcare Provider Details

I. General information

NPI: 1386475416
Provider Name (Legal Business Name): DANIEL DAVID JOHNSON ATC, LAT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/10/2024
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 17TH AVE N
FARGO ND
58102
US

IV. Provider business mailing address

PO BOX 6050 DEPT 1200
FARGO ND
58108
US

V. Phone/Fax

Practice location:
  • Phone: 651-925-6115
  • Fax:
Mailing address:
  • Phone: 651-925-6115
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number1216-25
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: