Provider Demographics
NPI:1487605283
Name:JOHNSON, JOHN ROBERT (CRNA)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:ROBERT
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 14806
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43214-0806
Mailing Address - Country:US
Mailing Address - Phone:614-261-3723
Mailing Address - Fax:614-447-9593
Practice Address - Street 1:3300 WELTY RD
Practice Address - Street 2:
Practice Address - City:LUCAS
Practice Address - State:OH
Practice Address - Zip Code:44843-9729
Practice Address - Country:US
Practice Address - Phone:419-566-4152
Practice Address - Fax:419-842-3875
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2013-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN140884367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
430062329OtherMEDICARE RAILROAD
000000187654OtherANTHEM
OH0909726Medicaid
OH0909726Medicaid