Basic Information
| Provider Information | |||||||||
| NPI: | 1053372037 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON-SMITH | ||||||||
| FirstName: | JILL | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | JOHNSON-SMITH | ||||||||
| OtherFirstName: | JILL | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | PA-C | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 8035 | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672080035 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3166899135 | ||||||||
| FaxNumber: | 3166899667 | ||||||||
| Practice Location | |||||||||
| Address1: | 612 N ANDOVER RD | ||||||||
| Address2: | |||||||||
| City: | ANDOVER | ||||||||
| State: | KS | ||||||||
| PostalCode: | 670029778 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3167336618 | ||||||||
| FaxNumber: | 3167335299 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/30/2006 | ||||||||
| LastUpdateDate: | 06/13/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 15-00074 | KS | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 100385390D | 05 | KS | MEDICAID | 003719232 | 01 | MEDICARE | OTHER |