Basic Information
| Provider Information | |||||||||
| NPI: | 1871884742 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | ROGER | ||||||||
| MiddleName: | DALTON | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1245 | ||||||||
| Address2: | |||||||||
| City: | ORANGEBURG | ||||||||
| State: | SC | ||||||||
| PostalCode: | 291161245 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8033954497 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3000 SAINT MATTHEWS RD | ||||||||
| Address2: | |||||||||
| City: | ORANGEBURG | ||||||||
| State: | SC | ||||||||
| PostalCode: | 291181442 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8033952200 | ||||||||
| FaxNumber: | 8033952304 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/27/2011 | ||||||||
| LastUpdateDate: | 11/09/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 100263 | SC | N | Nursing Service Providers | Registered Nurse | 367500000X | 17516 | SC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | GP2825 | 05 | SC | MEDICAID |