Healthcare Provider Details

I. General information

NPI: 1336628486
Provider Name (Legal Business Name): BRADLEY ALLEN JOHNSON CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2018
Last Update Date: 03/03/2020
Certification Date: 03/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11511 NE 10TH ST
BELLEVUE WA
98004-8578
US

IV. Provider business mailing address

11511 NE 10TH ST
BELLEVUE WA
98004-8578
US

V. Phone/Fax

Practice location:
  • Phone: 425-502-3000
  • Fax: 425-502-3589
Mailing address:
  • Phone: 425-502-3000
  • Fax: 425-502-3589

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAP60897170
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: