Provider Demographics
NPI:1154789741
Name:JOHNSON, ENRICO RAMON (NP-C)
Entity type:Individual
Prefix:
First Name:ENRICO
Middle Name:RAMON
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1415 LILAC DR N STE 190
Mailing Address - Street 2:
Mailing Address - City:GOLDEN VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55422-4544
Mailing Address - Country:US
Mailing Address - Phone:763-267-8701
Mailing Address - Fax:763-231-9602
Practice Address - Street 1:1925 WOODWINDS DR
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-4445
Practice Address - Country:US
Practice Address - Phone:651-232-0100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-10
Last Update Date:2019-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNCNP 4417363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner