Basic Information
| Provider Information | |||||||||
| NPI: | 1730125816 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHANNSEN | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1027 WASHINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | DETROIT LAKES | ||||||||
| State: | MN | ||||||||
| PostalCode: | 565013409 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2188475611 | ||||||||
| FaxNumber: | 2188470881 | ||||||||
| Practice Location | |||||||||
| Address1: | 1027 WASHINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | DETROIT LAKES | ||||||||
| State: | MN | ||||||||
| PostalCode: | 565013409 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2188475611 | ||||||||
| FaxNumber: | 2188470881 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2006 | ||||||||
| LastUpdateDate: | 07/19/2012 | ||||||||
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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 | R141280-4 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 033G2JO | 01 | MN | MNBS # | OTHER | 1697627 | 01 | MN | AMERICA'S PPO/ARAZ # | OTHER | 1730125816 | 05 | MN | MEDICAID | 23758 | 01 | MN | NDBS # | OTHER | DA9031034432 | 01 | MN | PREFERRED ONE # | OTHER | 12694 | 05 | MN | MEDICAID | 2001891 | 01 | MN | MEDICA # | OTHER | 24174 | 01 | MN | LHS/BANNERHEALTH # | OTHER | HP38479 | 01 | MN | HEALTHPARTNERS # | OTHER | 150582300 | 05 | MN | MEDICAID |