Healthcare Provider Details

I. General information

NPI: 1134441256
Provider Name (Legal Business Name): MR. SOREN A JOHNSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/16/2010
Last Update Date: 02/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3878 BLISS RD
MORRISVILLE NY
13408-2218
US

IV. Provider business mailing address

3878 BLISS RD
MORRISVILLE NY
13408-2218
US

V. Phone/Fax

Practice location:
  • Phone: 315-684-9105
  • Fax: 315-684-9105
Mailing address:
  • Phone: 315-684-9105
  • Fax: 315-684-9105

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number2937261
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: