Basic Information
| Provider Information | |||||||||
| NPI: | 1255667440 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | PAUL | ||||||||
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| Credential: | APN, FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1600 N MAIN AVE | ||||||||
| Address2: | |||||||||
| City: | LOVINGTON | ||||||||
| State: | NM | ||||||||
| PostalCode: | 882602813 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5753966611 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1600 N MAIN AVE | ||||||||
| Address2: | |||||||||
| City: | LOVINGTON | ||||||||
| State: | NM | ||||||||
| PostalCode: | 882602813 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5753966611 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/23/2009 | ||||||||
| LastUpdateDate: | 01/04/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 111N00000X | 3061 | CO | N | Chiropractic Providers | Chiropractor | 163W00000X | 168340 | CO | N | Nursing Service Providers | Registered Nurse | 363L00000X | 10141 | CO | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | 61768 | NM | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 96657251 | 05 | CO | MEDICAID | 87703076 | 05 | NM | MEDICAID |