Provider Demographics
NPI:1366858581
Name:JOHNSON, JEREMY DELANE (CRNA)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:DELANE
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:PO BOX 50095
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98145-5095
Mailing Address - Country:US
Mailing Address - Phone:206-520-5700
Mailing Address - Fax:
Practice Address - Street 1:3300 OAKDALE AVE NORTH
Practice Address - Street 2:
Practice Address - City:ROBBINSDALE
Practice Address - State:MN
Practice Address - Zip Code:55422
Practice Address - Country:US
Practice Address - Phone:206-520-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-08
Last Update Date:2020-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN382367500000X
WAAP60813548367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered