Provider Demographics
NPI:1407819725
Name:JOHNSON, LARRY G (CRNA)
Entity Type:Individual
Prefix:MR
First Name:LARRY
Middle Name:G
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 1:1104 TUSCULUM BLVD
Mailing Address - Street 2:SUITE 303
Mailing Address - City:GREENEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37745-4091
Mailing Address - Country:US
Mailing Address - Phone:423-636-8600
Mailing Address - Fax:423-636-8892
Practice Address - Street 1:1104 TUSCULUM BLVD
Practice Address - Street 2:SUITE 303
Practice Address - City:GREENEVILLE
Practice Address - State:TN
Practice Address - Zip Code:37745-4091
Practice Address - Country:US
Practice Address - Phone:423-636-8600
Practice Address - Fax:423-636-8892
Is Sole Proprietor?:No
Enumeration Date:2006-04-08
Last Update Date:2008-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNRN0000030838367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN8050485OtherNC MEDICAID
TN0177990OtherBCBS OF TN
TN3600909Medicaid
TN3600909Medicaid