Healthcare Provider Details

I. General information

NPI: 1760553150
Provider Name (Legal Business Name): KRISTINA A JOHNSON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/10/2006
Last Update Date: 08/01/2023
Certification Date: 08/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3600 LINCOLN WAY
AMES IA
50014-7595
US

IV. Provider business mailing address

1215 DUFF AVE
AMES IA
50010-5469
US

V. Phone/Fax

Practice location:
  • Phone: 152-394-0775
  • Fax: 515-239-4758
Mailing address:
  • Phone: 515-235-9440
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number001768
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number001768
License Number StateIA
# 3
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number001768
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: