Healthcare Provider Details

I. General information

NPI: 1073684312
Provider Name (Legal Business Name): KEVIN BRADLEY JOHNSON CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/10/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35345 WOODLAND LN
ASTORIA OR
97103-8351
US

IV. Provider business mailing address

35345 WOODLAND LN
ASTORIA OR
97103-8351
US

V. Phone/Fax

Practice location:
  • Phone: 503-325-4548
  • Fax:
Mailing address:
  • Phone: 503-325-4548
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number079043924CRNA
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: