Provider Demographics
NPI:1891381448
Name:JOHNSON, ROBERT G (SA-C)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:G
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:SA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 EXECUTIVE PARK DR
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:NH
Mailing Address - Zip Code:03110-6918
Mailing Address - Country:US
Mailing Address - Phone:603-587-4103
Mailing Address - Fax:
Practice Address - Street 1:3 EXECUTIVE PARK DR
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:NH
Practice Address - Zip Code:03110-6918
Practice Address - Country:US
Practice Address - Phone:603-587-4103
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-17
Last Update Date:2020-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
18-135246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH18-135OtherABSA