Provider Demographics
NPI:1609807080
Name:JOHNSON, RAYMOND (CRNA)
Entity Type:Individual
Prefix:
First Name:RAYMOND
Middle Name:
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 67000
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48267-0001
Mailing Address - Country:US
Mailing Address - Phone:952-442-9770
Mailing Address - Fax:952-442-3630
Practice Address - Street 1:6071 W OUTER DR
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48235-2624
Practice Address - Country:US
Practice Address - Phone:952-442-9770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2011-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704164114367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI104357320Medicaid
MIRJ164114OtherBLUE CROSS OF MI
MIRJ164114OtherBLUE CROSS OF MI
MI104357320Medicaid