Healthcare Provider Details

I. General information

NPI: 1205970365
Provider Name (Legal Business Name): LARRY DEAN JOHNSON PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/20/2007
Last Update Date: 05/26/2021
Certification Date: 05/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 BRANSON LANDING BLVD
BRANSON MO
65616-2052
US

IV. Provider business mailing address

PO BOX 802843
KANSAS CITY MO
64180-2843
US

V. Phone/Fax

Practice location:
  • Phone: 417-348-8646
  • Fax: 417-335-7529
Mailing address:
  • Phone: 417-269-7241
  • Fax: 417-269-7567

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA-263
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2018044339
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: