Healthcare Provider Details

I. General information

NPI: 1063571933
Provider Name (Legal Business Name): WILLIAM L JOHNSON CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/07/2006
Last Update Date: 01/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1106 YIOTIS WAY
COLUMBIA MO
65203-6660
US

IV. Provider business mailing address

1106 YIOTIS WAY
COLUMBIA MO
65203-6660
US

V. Phone/Fax

Practice location:
  • Phone: 573-673-6861
  • Fax: 573-443-2905
Mailing address:
  • Phone: 573-673-6861
  • Fax: 573-443-2905

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number132482
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: