Healthcare Provider Details

I. General information

NPI: 1043284409
Provider Name (Legal Business Name): DAVID R JOHNSON CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/14/2006
Last Update Date: 11/05/2021
Certification Date: 11/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MEDICAL CENTER DR
MORGANTOWN WV
26506-1200
US

IV. Provider business mailing address

1777 S MAIN ST
WASHINGTON PA
15301-8891
US

V. Phone/Fax

Practice location:
  • Phone: 304-598-4000
  • Fax:
Mailing address:
  • Phone: 724-228-3075
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN516921L
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAPRN87587
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: