Provider Demographics
NPI:1083993273
Name:JOHNSON, MOIS A (NP)
Entity Type:Individual
Prefix:MS
First Name:MOIS
Middle Name:A
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:MOIS
Other - Middle Name:A
Other - Last Name:ROGERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2301 E 20TH ST UNIT 6687
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87499-7231
Mailing Address - Country:US
Mailing Address - Phone:505-800-7335
Mailing Address - Fax:505-333-0444
Practice Address - Street 1:203 W MAIN ST
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-6244
Practice Address - Country:US
Practice Address - Phone:505-517-4181
Practice Address - Fax:505-333-0444
Is Sole Proprietor?:No
Enumeration Date:2011-08-05
Last Update Date:2023-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209000639363L00000X
NM53658363LF0000X, 363LP0808X
IL27001480363LF0000X
COC-APN.0002620-C-NP363LF0000X
IL277001480363LP0808X
COC-APN.002320-C-NP363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM96336021Medicaid