Provider Demographics
NPI:1932118940
Name:JOHNSON, RYAN D (CRNA)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:D
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 1447
Mailing Address - Street 2:
Mailing Address - City:LUFKIN
Mailing Address - State:TX
Mailing Address - Zip Code:75902-1447
Mailing Address - Country:US
Mailing Address - Phone:936-639-3036
Mailing Address - Fax:
Practice Address - Street 1:1201 W FRANK AVE
Practice Address - Street 2:
Practice Address - City:LUFKIN
Practice Address - State:TX
Practice Address - Zip Code:75904-3357
Practice Address - Country:US
Practice Address - Phone:936-639-3036
Practice Address - Fax:936-639-3064
Is Sole Proprietor?:No
Enumeration Date:2006-08-07
Last Update Date:2008-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX048803367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX85053UOtherBCBS
TX82683UOtherBCBS
TX82683UOtherBCBS
TX85053UOtherBCBS