Provider Demographics
NPI:1881633550
Name:JOHNSON, TIMOTHY A (CRNA)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:A
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 821
Mailing Address - Street 2:
Mailing Address - City:HAYS
Mailing Address - State:KS
Mailing Address - Zip Code:67601-0821
Mailing Address - Country:US
Mailing Address - Phone:785-628-8300
Mailing Address - Fax:785-623-4634
Practice Address - Street 1:2220 CANTERBURY DR
Practice Address - Street 2:
Practice Address - City:HAYS
Practice Address - State:KS
Practice Address - Zip Code:67601-2370
Practice Address - Country:US
Practice Address - Phone:785-628-8300
Practice Address - Fax:785-623-4634
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2014-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS54371367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100276330AMedicaid
KS100276330AMedicaid