Healthcare Provider Details

I. General information

NPI: 1265768444
Provider Name (Legal Business Name): MATTHEW DOUGLAS JOHNSON CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2009
Last Update Date: 12/29/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 WALLACE BLVD
AMARILLO TX
79106-1799
US

IV. Provider business mailing address

301 PARTRIDGE DR
AMARILLO TX
79124-1415
US

V. Phone/Fax

Practice location:
  • Phone: 480-734-4833
  • Fax:
Mailing address:
  • Phone: 480-734-4833
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number776455
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: