Healthcare Provider Details

I. General information

NPI: 1932162575
Provider Name (Legal Business Name): JIMMIE JOHNSON II CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2006
Last Update Date: 11/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 MARSHALL DR
BELTON TX
76513-3779
US

IV. Provider business mailing address

501 MARSHALL DR
BELTON TX
76513-3779
US

V. Phone/Fax

Practice location:
  • Phone: 254-338-5473
  • Fax: 254-613-4064
Mailing address:
  • Phone: 254-338-5473
  • Fax: 254-613-4064

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number684289
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: