MEDICARE: REGINALD JOHNSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	CNP-02926	NM

General Provider Information

NPI Number	:	1902254477
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	REGINALD JOHNSON

Provider Business Mailing Address
First Line	:	2409 W PIERCE ST
Second Line	:	SUITE A
City	:	CARLSBAD
State	:	NM
Zip	:	88220-3513
Country	:	US
Telephone Number	:	575-887-8925
Fax Number	:	575-887-8935

Provider Business Practice Location Address
First Line	:	2409 W PIERCE ST
Second Line	:	SUITE A
City	:	CARLSBAD
State	:	NM
Zip	:	88220-3513
Country	:	US
Telephone Number	:	575-887-8925
Fax Number	:	575-887-8935

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/25/2016
Last Update Date	:	06/14/2021

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Directions to “ REGINALD JOHNSON ” Practice Location

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