Healthcare Provider Details

I. General information

NPI: 1700362183
Provider Name (Legal Business Name): JOHN GRADY JOHNSTON JR. DNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/18/2018
Last Update Date: 04/03/2024
Certification Date: 04/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

42121 US HIGHWAY 70
PORTALES NM
88130-9054
US

IV. Provider business mailing address

506 VIALE BOND
ROSWELL NM
88201-5874
US

V. Phone/Fax

Practice location:
  • Phone: 575-359-1800
  • Fax:
Mailing address:
  • Phone: 731-616-8164
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041465807
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number120003
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number55422
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: