Provider Demographics
NPI:1073684312
Name:JOHNSON, KEVIN BRADLEY (CRNA)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:BRADLEY
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35345 WOODLAND LN
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:OR
Mailing Address - Zip Code:97103-8351
Mailing Address - Country:US
Mailing Address - Phone:503-325-4548
Mailing Address - Fax:
Practice Address - Street 1:35345 WOODLAND LN
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:OR
Practice Address - Zip Code:97103-8351
Practice Address - Country:US
Practice Address - Phone:503-325-4548
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-10
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR079043924CRNA367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9609439Medicaid
OR196407Medicaid
WA9609439Medicaid