Healthcare Provider Details

I. General information

NPI: 1508189812
Provider Name (Legal Business Name): JAMES KIM JOHNSON CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2010
Last Update Date: 03/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 N PEPPER AVE ANESTHESIA DEPT., 2ND FLOOR
COLTON CA
92324-1801
US

IV. Provider business mailing address

PO BOX 765
COLTON CA
92324-0800
US

V. Phone/Fax

Practice location:
  • Phone: 909-580-2440
  • Fax: 909-580-2441
Mailing address:
  • Phone: 909-580-2440
  • Fax: 909-580-2441

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberNA3887
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: