Basic Information
| Provider Information | |||||||||
| NPI: | 1760553150 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | KRISTINA | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2700 1ST AVE S STE 100 | ||||||||
| Address2: | |||||||||
| City: | FORT DODGE | ||||||||
| State: | IA | ||||||||
| PostalCode: | 505014300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5159556767 | ||||||||
| FaxNumber: | 5155768581 | ||||||||
| Practice Location | |||||||||
| Address1: | 2700 1ST AVE S STE 100 | ||||||||
| Address2: | |||||||||
| City: | FORT DODGE | ||||||||
| State: | IA | ||||||||
| PostalCode: | 505014300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5159556767 | ||||||||
| FaxNumber: | 5155768581 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/10/2006 | ||||||||
| LastUpdateDate: | 02/27/2017 | ||||||||
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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 | 363AS0400X | 001768 | IA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363A00000X | 001768 | IA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AM0700X | 001768 | IA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 35349 | 01 | IA | WELLMARK | OTHER | 8123083 | 05 | IA | MEDICAID | P00374217 | 01 | IA | RR MEDICARE | OTHER |