Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN1001X | Nutrition | 1651 | MN |
NPI | 1285931923 |
---|---|
Provider Name | Dr. Gary David Johnson |
First Address | Duluth, MN 55811 |
Second Address | Duluth, MN 55811-4432 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 15/02/2011 |
Last Update Date | 18/09/2013 |