Provider Demographics
NPI:1861483711
Name:JOHNSON, WENDI A (MD)
Entity type:Individual
Prefix:
First Name:WENDI
Middle Name:A
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:WENDI
Other - Middle Name:A
Other - Last Name:JOHNSON-HAAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:320 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CROSBY
Mailing Address - State:MN
Mailing Address - Zip Code:56441-1645
Mailing Address - Country:US
Mailing Address - Phone:218-546-7000
Mailing Address - Fax:218-546-4400
Practice Address - Street 1:320 E MAIN ST
Practice Address - Street 2:
Practice Address - City:CROSBY
Practice Address - State:MN
Practice Address - Zip Code:56441-1645
Practice Address - Country:US
Practice Address - Phone:218-546-7000
Practice Address - Fax:218-546-4400
Is Sole Proprietor?:No
Enumeration Date:2005-10-31
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN42414208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
127726OtherU CARE
COMPOtherCHAMPUS
370015800OtherRR MEDICARE
MN519112200Medicaid
COMPOtherMMSI
1200672OtherMEDICA HEALTH PLANS
2115882OtherFIRST HEALTH PLAN
940644OtherARAZ GROUP AMERICAS PPO
1023002OtherPREFERRED ONE
86D69HOOtherBLUE CROSS BLUE SHIELD
COMPOtherONE HEALTH PLAN GREAT WES
HP30134OtherHEALTH PARTNERS
1023002OtherPREFERRED ONE
MN519112200Medicaid