Provider Demographics
NPI:1497757314
Name:JOHNSON, PAUL M
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:M
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 1:8443 SW 113TH CT
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33173-4239
Mailing Address - Country:US
Mailing Address - Phone:912-980-4922
Mailing Address - Fax:
Practice Address - Street 1:1800 NW 10TH AVE STE T-215
Practice Address - Street 2:ARMY TRAUMA TRAINING CENTER, RYDER TRAUMA CENTER
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33136-1018
Practice Address - Country:US
Practice Address - Phone:912-585-1408
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-11
Last Update Date:2008-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN 254416 NA-06872367500000X
GARN174836 CRNA367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered