Healthcare Provider Details

I. General information

NPI: 1609869601
Provider Name (Legal Business Name): ROBERT RUSSELL JOHNSON CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2005
Last Update Date: 07/13/2026
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

336 DEERFIELD RD
BOONE NC
28607-5008
US

IV. Provider business mailing address

PO BOX 1181
SPRUCE PINE NC
28777-1181
US

V. Phone/Fax

Practice location:
  • Phone: 828-262-4241
  • Fax:
Mailing address:
  • Phone: 828-765-9928
  • Fax: 828-765-8042

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number56170
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: