Healthcare Provider Details

I. General information

NPI: 1245985712
Provider Name (Legal Business Name): MIKAYLA JOHNSON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/14/2022
Last Update Date: 02/01/2023
Certification Date: 02/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11501 MONTGOMERY BLVD NE
ALBUQUERQUE NM
87111-2796
US

IV. Provider business mailing address

812 TONY SANCHEZ DR SE
ALBUQUERQUE NM
87123-5936
US

V. Phone/Fax

Practice location:
  • Phone: 505-814-1333
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: