MEDICARE: MR. KEVIN WAYNE JOHNSON CRNA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	367500000X	Certified Registered Nurse Anesthetist	45551	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	00C68R	OTHER	TX	BCBSTX
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1750388120
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. KEVIN WAYNE JOHNSON CRNA

Provider Business Mailing Address
First Line	:	4030 GILBERT AVE
Second Line	:	APT 4
City	:	DALLAS
State	:	TX
Zip	:	75219-3869
Country	:	US
Telephone Number	:	214-526-3905
Fax Number	:

Provider Business Practice Location Address
First Line	:	4030 GILBERT AVE
Second Line	:	APT 4
City	:	DALLAS
State	:	TX
Zip	:	75219-3869
Country	:	US
Telephone Number	:	214-526-3905
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/30/2005
Last Update Date	:	05/12/2009

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