Healthcare Provider Details

I. General information

NPI: 1205225331
Provider Name (Legal Business Name): JOHNNY GAYDEN APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/13/2015
Last Update Date: 01/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 N GREENE ST
BALTIMORE MD
21201-1524
US

IV. Provider business mailing address

2 GREENVIEW AVE
REISTERSTOWN MD
21136-2402
US

V. Phone/Fax

Practice location:
  • Phone: 410-605-7000
  • Fax:
Mailing address:
  • Phone: 410-504-2521
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR183885
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: