Provider Demographics
NPI:1982663357
Name:JOHNSON, ANDREA L (CRNA)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:L
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 10TH ST E
Mailing Address - Street 2:
Mailing Address - City:WACONIA
Mailing Address - State:MN
Mailing Address - Zip Code:55387-4552
Mailing Address - Country:US
Mailing Address - Phone:888-209-0305
Mailing Address - Fax:952-442-3688
Practice Address - Street 1:17720 JEAN WAY STE 100
Practice Address - Street 2:
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-5575
Practice Address - Country:US
Practice Address - Phone:888-209-0305
Practice Address - Fax:952-442-3688
Is Sole Proprietor?:No
Enumeration Date:2006-03-22
Last Update Date:2020-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR 159670-4367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered