Provider Demographics
NPI:1750388120
Name:JOHNSON, KEVIN WAYNE (CRNA)
Entity type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:WAYNE
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 1:4030 GILBERT AVE
Mailing Address - Street 2:APT 4
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75219-3869
Mailing Address - Country:US
Mailing Address - Phone:214-526-3905
Mailing Address - Fax:
Practice Address - Street 1:4030 GILBERT AVE
Practice Address - Street 2:APT 4
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75219-3869
Practice Address - Country:US
Practice Address - Phone:214-526-3905
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-30
Last Update Date:2009-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX45551367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00C68ROtherBCBSTX
TX120052905Medicaid
TX120052905Medicaid
TX00201CMedicare PIN