Healthcare Provider Details

I. General information

NPI: 1154050003
Provider Name (Legal Business Name): MAKENNA JO JOHN PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2022
Last Update Date: 01/06/2026
Certification Date: 01/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3012 BROADWAY AVE
HAYS KS
67601-1916
US

IV. Provider business mailing address

3012 BROADWAY AVE
HAYS KS
67601-1916
US

V. Phone/Fax

Practice location:
  • Phone: 785-301-2250
  • Fax: 785-301-2270
Mailing address:
  • Phone: 785-301-2250
  • Fax: 785-301-2270

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number15-02693
License Number StateKS
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number15-02693
License Number StateKS
# 3
Primary TaxonomyN
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number15-02693
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: