Provider Demographics
NPI:1962190207
Name:JOHNSON, ANDREW TIMOTHY (RN)
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:TIMOTHY
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 S 62ND ST
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74014-6932
Mailing Address - Country:US
Mailing Address - Phone:918-932-7007
Mailing Address - Fax:
Practice Address - Street 1:5001 W 41ST ST
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57106-1424
Practice Address - Country:US
Practice Address - Phone:605-362-0100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-25
Last Update Date:2024-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0117101163W00000X
OK212932367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty