Healthcare Provider Details

I. General information

NPI: 1629337753
Provider Name (Legal Business Name): STEPHEN JOHNSTON PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2012
Last Update Date: 03/22/2021
Certification Date: 03/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 E 15TH ST STE 400A
EDMOND OK
73013-6673
US

IV. Provider business mailing address

19632 STRATMORE WAY
EDMOND OK
73012-2205
US

V. Phone/Fax

Practice location:
  • Phone: 405-341-1697
  • Fax: 405-341-2672
Mailing address:
  • Phone: 970-672-6952
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA-3428
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA2500
License Number StateOK
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2500
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: