Provider Demographics
NPI:1790755254
Name:JOHNSON, JAMES (CRNA)
Entity Type:Individual
Prefix:
First Name:JAMES
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 48483
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67201-8483
Mailing Address - Country:US
Mailing Address - Phone:316-685-6236
Mailing Address - Fax:
Practice Address - Street 1:1705 W 2ND ST
Practice Address - Street 2:
Practice Address - City:ELK CITY
Practice Address - State:OK
Practice Address - Zip Code:73644-4455
Practice Address - Country:US
Practice Address - Phone:580-225-2511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0082560367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200060570AMedicaid
OK53764799001OtherBCBS
P00258327OtherRAILROAD MEDICARE
P00258327OtherRAILROAD MEDICARE
245710602Medicare PIN
P00451357Medicare Oscar/Certification