Basic Information
| Provider Information | |||||||||
| NPI: | 1578865952 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | MEGAN | ||||||||
| MiddleName: | PAMELA | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KNAEBLE | ||||||||
| OtherFirstName: | MEGAN | ||||||||
| OtherMiddleName: | PAMELA | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 6405 FRANCE AVE S STE W400 | ||||||||
| Address2: | |||||||||
| City: | EDINA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554352165 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9529202730 | ||||||||
| FaxNumber: | 9525677090 | ||||||||
| Practice Location | |||||||||
| Address1: | 6405 FRANCE AVE S STE W400 | ||||||||
| Address2: | |||||||||
| City: | EDINA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554352165 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9529202730 | ||||||||
| FaxNumber: | 9525677090 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/17/2010 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 1862 | MN | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 085.003910 | IL | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 11292 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | ENROLLED | 05 | MN | MEDICAID |