Healthcare Provider Details

I. General information

NPI: 1992310700
Provider Name (Legal Business Name): COLTYN TYLER JOHNSON APRN, CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2020
Last Update Date: 12/11/2025
Certification Date: 12/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2525 CHICAGO AVE
MINNEAPOLIS MN
55404-4518
US

IV. Provider business mailing address

500 NE MULTNOMAH ST STE 100
PORTLAND OR
97232-2031
US

V. Phone/Fax

Practice location:
  • Phone: 612-813-6000
  • Fax:
Mailing address:
  • Phone: 800-813-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number10045538
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: