Healthcare Provider Details

I. General information

NPI: 1568427045
Provider Name (Legal Business Name): BRADLEY P JOHNSON CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2006
Last Update Date: 01/11/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

196 NORTH STREET
GENEVA NY
14456
US

IV. Provider business mailing address

202 TAUGHANNOCK BLVD. PO BOX 366
ITHACA NY
14851
US

V. Phone/Fax

Practice location:
  • Phone: 315-787-4533
  • Fax:
Mailing address:
  • Phone: 607-277-3257
  • Fax: 607-277-4056

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number532646
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: