Provider Demographics
NPI:1063571933
Name:JOHNSON, WILLIAM L (CRNA)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:L
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1106 YIOTIS WAY
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65203-6660
Mailing Address - Country:US
Mailing Address - Phone:573-673-6861
Mailing Address - Fax:573-443-2905
Practice Address - Street 1:1106 YIOTIS WAY
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65203-6660
Practice Address - Country:US
Practice Address - Phone:573-673-6861
Practice Address - Fax:573-443-2905
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-07
Last Update Date:2014-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO132482367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered