MEDICARE: NICOLE A JOHNSTON P.A.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AS0400X	Surgical Physician Assistant	2005032623	MO
2	363A00000X	Physician Assistant	10431	MN

General Provider Information

NPI Number	:	1538131883
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLE A JOHNSTON P.A.

Provider Business Mailing Address
First Line	:	2200 NW 26TH ST
Second Line	:
City	:	OWATONNA
State	:	MN
Zip	:	55060-5503
Country	:	US
Telephone Number	:	507-451-1120
Fax Number	:	507-444-6287

Provider Business Practice Location Address
First Line	:	2200 NW 26TH ST
Second Line	:
City	:	OWATONNA
State	:	MN
Zip	:	55060-5503
Country	:	US
Telephone Number	:	507-451-1120
Fax Number	:	507-444-6287

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/02/2006
Last Update Date	:	10/28/2008

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