Individual
GARY R JOHANSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
CRNA
Contact information
Practice address
1950 E CLARK ST, SUITE G, POCATELLO, ID 83201-3314
(208) 232-7760
(208) 232-1950
Mailing address
PO BOX 4107, POCATELLO, ID 83205-4107
(208) 232-7760
(208) 232-1950
Taxonomy
Speciality
Code
Description
License number
State
163W00000X
Registered Nurse
N15687
ID
367500000X
Certified Registered Nurse Anesthetist
Primary
RNA-28A
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
004371700
—
ID
Enumeration date
05/11/2006
Last updated
10/19/2011
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