Healthcare Provider Details

I. General information

NPI: 1467566331
Provider Name (Legal Business Name): WAYNE JOHNSON CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2006
Last Update Date: 05/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 N 21ST ST
ORD NE
68862-1320
US

IV. Provider business mailing address

120 N 21ST ST
ORD NE
68862-1320
US

V. Phone/Fax

Practice location:
  • Phone: 402-699-0736
  • Fax: 402-343-8765
Mailing address:
  • Phone: 402-699-0736
  • Fax: 402-343-8765

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number100500
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: