Healthcare Provider Details

I. General information

NPI: 1073906475
Provider Name (Legal Business Name): MICHAEL JOHNSON JR. CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/09/2015
Last Update Date: 03/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8166 MAIN ST
HOUMA LA
70360-3404
US

IV. Provider business mailing address

30 AMARILLO DR
HOUMA LA
70360-7286
US

V. Phone/Fax

Practice location:
  • Phone: 985-873-4141
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAP08147
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: