Healthcare Provider Details

I. General information

NPI: 1497757314
Provider Name (Legal Business Name): PAUL M. JOHNSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2005
Last Update Date: 12/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 NW 10TH AVE STE T-215 ARMY TRAUMA TRAINING CENTER, RYDER TRAUMA CENTER
MIAMI FL
33136-1018
US

IV. Provider business mailing address

8443 SW 113TH CT
MIAMI FL
33173-4239
US

V. Phone/Fax

Practice location:
  • Phone: 912-585-1408
  • Fax:
Mailing address:
  • Phone: 912-980-4922
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN 254416 NA-06872
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN174836 CRNA
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: