Provider Demographics
NPI:1235806027
Name:JOHNSON, RAFE ANTHONY
Entity Type:Individual
Prefix:MR
First Name:RAFE
Middle Name:ANTHONY
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 1:1304 DENMARK CT
Mailing Address - Street 2:
Mailing Address - City:SLIDELL
Mailing Address - State:LA
Mailing Address - Zip Code:70461-4561
Mailing Address - Country:US
Mailing Address - Phone:678-392-6081
Mailing Address - Fax:
Practice Address - Street 1:1304 DENMARK CT
Practice Address - Street 2:
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70461-4561
Practice Address - Country:US
Practice Address - Phone:678-392-6081
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-27
Last Update Date:2021-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA007709423343900000X
LA82-1264661343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)