Provider Demographics
NPI:1609654219
Name:JOHNSON, GLADE WARREN (CRNA, BSN)
Entity Type:Individual
Prefix:
First Name:GLADE
Middle Name:WARREN
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:CRNA, BSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21263 W SYCAMORE DR
Mailing Address - Street 2:
Mailing Address - City:BUCKEYE
Mailing Address - State:AZ
Mailing Address - Zip Code:85396-7898
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13677 W MCDOWELL RD
Practice Address - Street 2:
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85395-2635
Practice Address - Country:US
Practice Address - Phone:623-882-1500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-15
Last Update Date:2023-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ297873367500000X
UT10836809-3102163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse