Provider Demographics
NPI:1508189812
Name:JOHNSON, JAMES KIM (CRNA)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:KIM
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 765
Mailing Address - Street 2:
Mailing Address - City:COLTON
Mailing Address - State:CA
Mailing Address - Zip Code:92324-0800
Mailing Address - Country:US
Mailing Address - Phone:909-580-2440
Mailing Address - Fax:909-580-2441
Practice Address - Street 1:400 N PEPPER AVE
Practice Address - Street 2:ANESTHESIA DEPT., 2ND FLOOR
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324-1801
Practice Address - Country:US
Practice Address - Phone:909-580-2440
Practice Address - Fax:909-580-2441
Is Sole Proprietor?:No
Enumeration Date:2010-03-02
Last Update Date:2010-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANA3887367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered