Provider Demographics
NPI:1730125816
Name:JOHANNSEN, JEFFREY R (CRNA)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:R
Last Name:JOHANNSEN
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 1:1027 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT LAKES
Mailing Address - State:MN
Mailing Address - Zip Code:56501-3409
Mailing Address - Country:US
Mailing Address - Phone:218-847-5611
Mailing Address - Fax:218-847-0881
Practice Address - Street 1:1027 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:DETROIT LAKES
Practice Address - State:MN
Practice Address - Zip Code:56501-3409
Practice Address - Country:US
Practice Address - Phone:218-847-5611
Practice Address - Fax:218-847-0881
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2012-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR141280-4367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN033G2JOOtherMNBS #
MN1697627OtherAMERICA'S PPO/ARAZ #
MN1730125816Medicaid
MN23758OtherNDBS #
MNDA9031034432OtherPREFERRED ONE #
MN12694Medicaid
MN2001891OtherMEDICA #
MN24174OtherLHS/BANNERHEALTH #
MNHP38479OtherHEALTHPARTNERS #
MN150582300Medicaid
MNP00103457Medicare ID - Type UnspecifiedRR MEDICARE #
MN12694Medicaid