Basic Information
| Provider Information | |||||||||
| NPI: | 1639192446 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | JAIME | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8100 S WALKER AVE BLDG A | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731399475 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4056324468 | ||||||||
| FaxNumber: | 4056320436 | ||||||||
| Practice Location | |||||||||
| Address1: | 2506 N HARRISON ST | ||||||||
| Address2: | |||||||||
| City: | SHAWNEE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 74804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4053959050 | ||||||||
| FaxNumber: | 4053959630 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2006 | ||||||||
| LastUpdateDate: | 04/23/2019 | ||||||||
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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 | 1198 | OK | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AM0700X | 1198 | OK | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 1198 | 01 | OK | MEDICAL LICENSE | OTHER |