Provider Demographics
NPI:1215979463
Name:JOHNSON, PHILIP THOMAS (CRNA)
Entity type:Individual
Prefix:
First Name:PHILIP
Middle Name:THOMAS
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 1:360 STATE ST
Mailing Address - Street 2:APT. 2608
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06510-3601
Mailing Address - Country:US
Mailing Address - Phone:310-902-7247
Mailing Address - Fax:
Practice Address - Street 1:20 YORK ST
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06510-3220
Practice Address - Country:US
Practice Address - Phone:203-688-6963
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2016-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA3293367500000X
FLARNP9298728367500000X
CT4055367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1048135Medicaid
CARN4326530Medicaid
LA3A624C734Medicare PIN
Q62129Medicare UPIN
LA1048135Medicaid
LA1048135Medicaid