Provider Demographics
NPI:1982648093
Name:JOHNSON, WENDY (MD)
Entity Type:Individual
Prefix:DR
First Name:WENDY
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1035 ALTO ST
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87501-2406
Mailing Address - Country:US
Mailing Address - Phone:505-982-4599
Mailing Address - Fax:505-982-8440
Practice Address - Street 1:1035 ALTO ST
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87501-2406
Practice Address - Country:US
Practice Address - Phone:505-982-4599
Practice Address - Fax:505-982-8440
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2023-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00047755207Q00000X
OH35074913207Q00000X
NM98-299207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2072073Medicaid
OH2072073Medicaid
OHG87329Medicare UPIN