Basic Information
| Provider Information | |||||||||
| NPI: | 1437123361 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSEN | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | W | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 36840 | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871766840 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052437729 | ||||||||
| FaxNumber: | 5052434804 | ||||||||
| Practice Location | |||||||||
| Address1: | 4401 MASTHEAD ST NE | ||||||||
| Address2: | SUITE 120 | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871094493 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052437729 | ||||||||
| FaxNumber: | 5052434804 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2006 | ||||||||
| LastUpdateDate: | 06/16/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/16/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | S1831 | TX | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207L00000X | 2001-223 | NM | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | E1113 | 05 | NM | MEDICAID |