Basic Information
| Provider Information | |||||||||
| NPI: | 1225014939 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | SCOTT | ||||||||
| MiddleName: | R. | ||||||||
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| Credential: | C.R.N.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 249 | ||||||||
| Address2: | |||||||||
| City: | GLADSTONE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970270249 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036504359 | ||||||||
| FaxNumber: | 5036506913 | ||||||||
| Practice Location | |||||||||
| Address1: | 800 E WASHINGTON BLVD | ||||||||
| Address2: | |||||||||
| City: | CRESCENT CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 955318359 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036504359 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/15/2005 | ||||||||
| LastUpdateDate: | 10/25/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 3462 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.