Healthcare Provider Details

I. General information

NPI: 1700836418
Provider Name (Legal Business Name): GARY R JOHANSON CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2006
Last Update Date: 10/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1950 E CLARK ST SUITE G
POCATELLO ID
83201-3314
US

IV. Provider business mailing address

PO BOX 4107
POCATELLO ID
83205-4107
US

V. Phone/Fax

Practice location:
  • Phone: 208-232-7760
  • Fax: 208-232-1950
Mailing address:
  • Phone: 208-232-7760
  • Fax: 208-232-1950

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberN15687
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRNA-28A
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: