Healthcare Provider Details

I. General information

NPI: 1124005988
Provider Name (Legal Business Name): KURT SAMUEL JOHNSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/22/2005
Last Update Date: 09/13/2023
Certification Date: 09/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 E UNIVERSITY AVE
LARAMIE WY
82071-2000
US

IV. Provider business mailing address

1000 E UNIVERSITY AVE
LARAMIE WY
82071-2000
US

V. Phone/Fax

Practice location:
  • Phone: 307-766-5071
  • Fax: 307-761-9319
Mailing address:
  • Phone: 307-766-5071
  • Fax: 307-766-2112

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number6832A
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: