Basic Information
| Provider Information | |||||||||
| NPI: | 1063024891 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | NATHAN | ||||||||
| MiddleName: | ALLEN | ||||||||
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| Credential: | FNP-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 30323 VAN HORN RD | ||||||||
| Address2: | |||||||||
| City: | NEW BOSTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481649499 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7345526062 | ||||||||
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| Practice Location | |||||||||
| Address1: | 9315 TELEGRAPH RD | ||||||||
| Address2: | |||||||||
| City: | REDFORD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482391260 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3134504500 | ||||||||
| FaxNumber: | 3134504512 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/22/2020 | ||||||||
| LastUpdateDate: | 01/25/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 4704298402 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.