Provider Demographics
NPI:1447232095
Name:JOHNSON, SAMMY B (CRNA)
Entity Type:Individual
Prefix:
First Name:SAMMY
Middle Name:B
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 1:17133 FM 832
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:TX
Mailing Address - Zip Code:75831-6211
Mailing Address - Country:US
Mailing Address - Phone:936-544-4255
Mailing Address - Fax:936-544-4409
Practice Address - Street 1:3323 S LOOP 256
Practice Address - Street 2:
Practice Address - City:PALESTINE
Practice Address - State:TX
Practice Address - Zip Code:75801-6977
Practice Address - Country:US
Practice Address - Phone:936-544-4255
Practice Address - Fax:936-544-4409
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX238328163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00C40BMedicare ID - Type Unspecified