Healthcare Provider Details

I. General information

NPI: 1346773512
Provider Name (Legal Business Name): COLIN JOHNSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2017
Last Update Date: 10/21/2025
Certification Date: 10/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3232 N BALLARD RD STE 100
APPLETON WI
54911-8804
US

IV. Provider business mailing address

3232 N BALLARD RD STE 100
APPLETON WI
54911-8804
US

V. Phone/Fax

Practice location:
  • Phone: 920-729-7105
  • Fax: 920-739-2609
Mailing address:
  • Phone: 920-729-7105
  • Fax: 920-831-8306

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207VF0040X
TaxonomyUrogynecology and Reconstructive Pelvic Surgery (Obstetrics & Gynecology) Physician
License NumberMD-49494
License Number StateIA
# 2
Primary TaxonomyY
Taxonomy Code207VF0040X
TaxonomyUrogynecology and Reconstructive Pelvic Surgery (Obstetrics & Gynecology) Physician
License Number70977
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number70977
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: