Provider Demographics
NPI:1497844203
Name:JOHNSON, SABRINA M (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:SABRINA
Middle Name:M
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:610 BROADWAY BLVD NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87102-2372
Mailing Address - Country:US
Mailing Address - Phone:505-225-2500
Mailing Address - Fax:505-225-2025
Practice Address - Street 1:610 BROADWAY BLVD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-2372
Practice Address - Country:US
Practice Address - Phone:505-225-2500
Practice Address - Fax:505-225-2025
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2021-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA2005-0037363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM47030763Medicaid