Provider Demographics
NPI:1700625357
Name:JOHNSON, LEO CLAUSEN
Entity type:Individual
Prefix:
First Name:LEO
Middle Name:CLAUSEN
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1883 GOODRICH AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55105-1543
Mailing Address - Country:US
Mailing Address - Phone:815-353-0623
Mailing Address - Fax:
Practice Address - Street 1:2211 RIVERSIDE AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55454-1350
Practice Address - Country:US
Practice Address - Phone:612-330-1399
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-22
Last Update Date:2024-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program