Healthcare Provider Details

I. General information

NPI: 1417400896
Provider Name (Legal Business Name): DAVID N JOHNSTON JR. CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/02/2016
Last Update Date: 08/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15190 COMMUNITY RD
GULFPORT MS
39503-3485
US

IV. Provider business mailing address

12146 DEDEAUX RD
GULFPORT MS
39503-5909
US

V. Phone/Fax

Practice location:
  • Phone: 228-831-0204
  • Fax: 228-831-1868
Mailing address:
  • Phone: 228-284-9442
  • Fax: 228-831-1868

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR901362
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: