Individual
EDDIE LEE JOHNSON JR.
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
CRNA
Contact information
Practice address
3200 MACCORKLE AVE SE, CHARLESTON, WV 25304
(304) 388-4077
(304) 388-9852
Mailing address
833 SAUNDERS ST, ST ALBANS, WV 25177
(304) 546-4189
Taxonomy
Speciality
Code
Description
License number
State
163W00000X
Registered Nurse
54873
WV
367500000X
Certified Registered Nurse Anesthetist
Primary
290824
NC
367500000X
Certified Registered Nurse Anesthetist
70139
WV
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
2603380000
—
WV
01
—
P00116681
MEDICARE RR
WV
Enumeration date
09/21/2006
Last updated
03/17/2021
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