Healthcare Provider Details

I. General information

NPI: 1104754274
Provider Name (Legal Business Name): TREVOR JOHNSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/11/2026
Last Update Date: 05/11/2026
Certification Date: 05/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 E VETERANS ST
TOMAH WI
54660-3105
US

IV. Provider business mailing address

500 E VETERANS ST
TOMAH WI
54660-3105
US

V. Phone/Fax

Practice location:
  • Phone: 608-784-3886
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP2201X
TaxonomyAmbulatory Care Registered Nurse
License Number2358420
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: