Healthcare Provider Details

I. General information

NPI: 1730781451
Provider Name (Legal Business Name): KARL ALAN JOHNSON FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2020
Last Update Date: 12/31/2024
Certification Date: 12/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1551 S SECOND ST
GALLUP NM
87301-5881
US

IV. Provider business mailing address

1551 S SECOND ST
GALLUP NM
87301-5881
US

V. Phone/Fax

Practice location:
  • Phone: 505-542-0090
  • Fax: 505-542-0155
Mailing address:
  • Phone: 505-542-0090
  • Fax: 505-542-0155

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number11032336-4405
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number1093694
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number80531
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: