Healthcare Provider Details

I. General information

NPI: 1619784550
Provider Name (Legal Business Name): CHAD JOHNSON CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/13/2024
Last Update Date: 12/13/2024
Certification Date: 12/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11800 ASTORIA BLVD
HOUSTON TX
77089-6041
US

IV. Provider business mailing address

31322 HORSESHOE MEADOW BEND LN
FULSHEAR TX
77441-2321
US

V. Phone/Fax

Practice location:
  • Phone: 713-400-2990
  • Fax:
Mailing address:
  • Phone: 717-448-7684
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number1169093
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: