Healthcare Provider Details

I. General information

NPI: 1760449698
Provider Name (Legal Business Name): JOHNNY W REED PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2006
Last Update Date: 04/03/2025
Certification Date: 04/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 N SILVER ST
SILVER CITY NM
88061-7201
US

IV. Provider business mailing address

1618 E PINE ST
SILVER CITY NM
88061-7155
US

V. Phone/Fax

Practice location:
  • Phone: 575-388-1889
  • Fax: 575-388-9952
Mailing address:
  • Phone: 575-388-1561
  • Fax: 575-388-9952

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2003-0002
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: