Provider Demographics
NPI:1578811527
Name:JOHNSON, GREG L (MS, BPS, PTA)
Entity Type:Individual
Prefix:
First Name:GREG
Middle Name:L
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MS, BPS, PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4201B QUAY ROAD 66
Mailing Address - Street 2:
Mailing Address - City:TUCUMCARI
Mailing Address - State:NM
Mailing Address - Zip Code:88401-9524
Mailing Address - Country:US
Mailing Address - Phone:615-618-2057
Mailing Address - Fax:
Practice Address - Street 1:305 E MIEL DE LUNA AVE
Practice Address - Street 2:
Practice Address - City:TUCUMCARI
Practice Address - State:NM
Practice Address - Zip Code:88401-3810
Practice Address - Country:US
Practice Address - Phone:575-461-7230
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-23
Last Update Date:2012-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMA-0767225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant