Provider Demographics
NPI:1083886212
Name:JOHNSON, NATHANIEL REAGOR (MD)
Entity Type:Individual
Prefix:
First Name:NATHANIEL
Middle Name:REAGOR
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2746 N WARREN AVE
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85719-3142
Mailing Address - Country:US
Mailing Address - Phone:505-264-9790
Mailing Address - Fax:520-626-2480
Practice Address - Street 1:2746 N WARREN AVE
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85719-3142
Practice Address - Country:US
Practice Address - Phone:505-264-9790
Practice Address - Fax:520-626-2480
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-27
Last Update Date:2008-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ80809207PP0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PP0204XAllopathic & Osteopathic PhysiciansEmergency MedicinePediatric Emergency Medicine