Basic Information
| Provider Information | |||||||||
| NPI: | 1336419969 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | RYAN | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | C.R.N.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 202 PROSPECT DR | ||||||||
| Address2: | |||||||||
| City: | GLENDIVE | ||||||||
| State: | MT | ||||||||
| PostalCode: | 593301943 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4063453306 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 202 PROSPECT DR | ||||||||
| Address2: | |||||||||
| City: | GLENDIVE | ||||||||
| State: | MT | ||||||||
| PostalCode: | 593301943 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4063453306 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/12/2012 | ||||||||
| LastUpdateDate: | 02/18/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 24911.1170 | WY | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | 28200422A | IN | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | R057004 | ME | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | NUR-APRN-LIC-101178 | MT | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.