Provider Demographics
NPI:1730781451
Name:JOHNSON, KARL ALAN (FNP-C)
Entity type:Individual
Prefix:
First Name:KARL
Middle Name:ALAN
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1551 S SECOND ST
Mailing Address - Street 2:
Mailing Address - City:GALLUP
Mailing Address - State:NM
Mailing Address - Zip Code:87301-5881
Mailing Address - Country:US
Mailing Address - Phone:505-542-0090
Mailing Address - Fax:505-542-0155
Practice Address - Street 1:1551 S SECOND ST
Practice Address - Street 2:
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87301-5881
Practice Address - Country:US
Practice Address - Phone:505-542-0090
Practice Address - Fax:505-542-0155
Is Sole Proprietor?:No
Enumeration Date:2020-11-09
Last Update Date:2024-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11032336-4405363L00000X
TX1093694363L00000X
NM80531363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner