Healthcare Provider Details

I. General information

NPI: 1699067546
Provider Name (Legal Business Name): FREDRICK G. JOHNSON C.R.N.F.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2011
Last Update Date: 04/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4320 E PRESIDIO ST #101
MESA AZ
85215
US

IV. Provider business mailing address

5155 E EAGLE DR #20730
MESA AZ
85277-3031
US

V. Phone/Fax

Practice location:
  • Phone: 480-706-9430
  • Fax:
Mailing address:
  • Phone: 480-229-7254
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WR0006X
TaxonomyRegistered Nurse First Assistant
License NumberRN143974
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: