Healthcare Provider Details

I. General information

NPI: 1902254477
Provider Name (Legal Business Name): REGINALD JOHNSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2016
Last Update Date: 06/14/2021
Certification Date: 06/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2409 W PIERCE ST SUITE A
CARLSBAD NM
88220-3513
US

IV. Provider business mailing address

2409 W PIERCE ST SUITE A
CARLSBAD NM
88220-3513
US

V. Phone/Fax

Practice location:
  • Phone: 575-887-8925
  • Fax: 575-887-8935
Mailing address:
  • Phone: 575-887-8925
  • Fax: 575-887-8935

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCNP-02926
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: