Provider Demographics
NPI:1871884742
Name:JOHNSON, ROGER DALTON (CRNA)
Entity type:Individual
Prefix:
First Name:ROGER
Middle Name:DALTON
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:PO BOX 1245
Mailing Address - Street 2:
Mailing Address - City:ORANGEBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29116-1245
Mailing Address - Country:US
Mailing Address - Phone:803-395-4497
Mailing Address - Fax:
Practice Address - Street 1:3000 SAINT MATTHEWS RD
Practice Address - Street 2:
Practice Address - City:ORANGEBURG
Practice Address - State:SC
Practice Address - Zip Code:29118-1442
Practice Address - Country:US
Practice Address - Phone:803-395-2200
Practice Address - Fax:803-395-2304
Is Sole Proprietor?:No
Enumeration Date:2011-04-27
Last Update Date:2020-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC100263163W00000X
SC17516367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP2825Medicaid
SCGP2825Medicaid