Provider Demographics
NPI:1134441256
Name:JOHNSON, SOREN A
Entity type:Individual
Prefix:MR
First Name:SOREN
Middle Name:A
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3878 BLISS RD
Mailing Address - Street 2:
Mailing Address - City:MORRISVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13408-2218
Mailing Address - Country:US
Mailing Address - Phone:315-684-9105
Mailing Address - Fax:315-684-9105
Practice Address - Street 1:3878 BLISS RD
Practice Address - Street 2:
Practice Address - City:MORRISVILLE
Practice Address - State:NY
Practice Address - Zip Code:13408-2218
Practice Address - Country:US
Practice Address - Phone:315-684-9105
Practice Address - Fax:315-684-9105
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-16
Last Update Date:2010-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2937261164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse