Basic Information
| Provider Information | |||||||||
| NPI: | 1154789741 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | ENRICO | ||||||||
| MiddleName: | RAMON | ||||||||
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| Credential: | NP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1415 LILAC DR N STE 190 | ||||||||
| Address2: | |||||||||
| City: | GOLDEN VALLEY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554224544 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7632678701 | ||||||||
| FaxNumber: | 7632319602 | ||||||||
| Practice Location | |||||||||
| Address1: | 1925 WOODWINDS DR | ||||||||
| Address2: | |||||||||
| City: | WOODBURY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551254445 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6512320100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/10/2016 | ||||||||
| LastUpdateDate: | 02/08/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | CNP 4417 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.