Provider Demographics
NPI:1265768444
Name:JOHNSON, MATTHEW DOUGLAS (CRNA)
Entity type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:DOUGLAS
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 1:301 PARTRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79124-1415
Mailing Address - Country:US
Mailing Address - Phone:480-734-4833
Mailing Address - Fax:
Practice Address - Street 1:1600 WALLACE BLVD
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79106-1799
Practice Address - Country:US
Practice Address - Phone:480-734-4833
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-23
Last Update Date:2013-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX776455367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered