Healthcare Provider Details

I. General information

NPI: 1588764583
Provider Name (Legal Business Name): TIMOTHY BART JOHNSON CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/22/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

79568 SUMNER ROAD
BROKEN BOW NE
68822
US

IV. Provider business mailing address

79568 SUMNER ROAD
BROKEN BOW NE
68822
US

V. Phone/Fax

Practice location:
  • Phone: 308-872-2294
  • Fax: 308-872-6272
Mailing address:
  • Phone: 308-872-2294
  • Fax: 308-872-6272

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number100588
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: