Basic Information
| Provider Information | |||||||||
| NPI: | 1699067546 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | FREDRICK | ||||||||
| MiddleName: | G. | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | C.R.N.F.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5155 E EAGLE DR | ||||||||
| Address2: | #20730 | ||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852773031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4802297254 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4320 E PRESIDIO ST | ||||||||
| Address2: | #101 | ||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4807069430 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2011 | ||||||||
| LastUpdateDate: | 04/18/2018 | ||||||||
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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 | 163WR0006X | RN143974 | AZ | Y | Nursing Service Providers | Registered Nurse | Registered Nurse First Assistant |
No ID Information.