Provider Demographics
NPI:1194732131
Name:JOHNSON, KATHY L (LPAC)
Entity type:Individual
Prefix:
First Name:KATHY L
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LPAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:933 BRADBURY DR SE
Mailing Address - Street 2:SUITE 2222
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106-4374
Mailing Address - Country:US
Mailing Address - Phone:505-272-3120
Mailing Address - Fax:505-272-8060
Practice Address - Street 1:1101 MEDICAL ARTS AVE NE
Practice Address - Street 2:SUITE 2 SENIOR HEALTH CLINIC
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-2706
Practice Address - Country:US
Practice Address - Phone:505-272-1754
Practice Address - Fax:505-925-4594
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2012-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA2003-0046363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant