Provider Demographics
NPI:1134664295
Name:JOHNSON, TAYLOR (CRNA)
Entity Type:Individual
Prefix:
First Name:TAYLOR
Middle Name:
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 1:3601 4TH ST # 1B350S
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79430-0002
Mailing Address - Country:US
Mailing Address - Phone:806-743-6639
Mailing Address - Fax:
Practice Address - Street 1:3601 4TH ST # 1B350S
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79430-0002
Practice Address - Country:US
Practice Address - Phone:806-743-6639
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-28
Last Update Date:2021-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK130052367500000X
TX786035367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered