Provider Demographics
NPI:1760449698
Name:REED, JOHNNY W (PAC)
Entity Type:Individual
Prefix:
First Name:JOHNNY
Middle Name:W
Last Name:REED
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 E 32ND ST
Mailing Address - Street 2:
Mailing Address - City:SILVER CITY
Mailing Address - State:NM
Mailing Address - Zip Code:88061-7287
Mailing Address - Country:US
Mailing Address - Phone:505-538-2981
Mailing Address - Fax:505-388-3373
Practice Address - Street 1:1600 E 32ND ST
Practice Address - Street 2:
Practice Address - City:SILVER CITY
Practice Address - State:NM
Practice Address - Zip Code:88061-7287
Practice Address - Country:US
Practice Address - Phone:505-538-2981
Practice Address - Fax:505-388-3373
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2013-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA2003-0002363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM69230030Medicaid
NM69230030Medicaid