Provider Demographics
NPI:1700362183
Name:JOHNSTON, JOHN GRADY JR (DNP)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:GRADY
Last Name:JOHNSTON
Suffix:JR
Gender:M
Credentials:DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:506 VIALE BOND
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88201-5874
Mailing Address - Country:US
Mailing Address - Phone:731-616-8164
Mailing Address - Fax:
Practice Address - Street 1:42121 US HIGHWAY 70
Practice Address - Street 2:
Practice Address - City:PORTALES
Practice Address - State:NM
Practice Address - Zip Code:88130-9054
Practice Address - Country:US
Practice Address - Phone:575-359-1800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-18
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041465807163W00000X
IL120003367500000X
NM55422367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse