=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306193727
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NICK JANSEN PA-C
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/06/2012
-----------------------------------------------------
Last Update Date | 10/23/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | SONGSONG VILLAGE
-----------------------------------------------------
City | ROTA
-----------------------------------------------------
State | MP
-----------------------------------------------------
Zip | 96951-1249
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 670-532-9461
-----------------------------------------------------
Fax | 670-532-0698
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1249
-----------------------------------------------------
City | ROTA
-----------------------------------------------------
State | MP
-----------------------------------------------------
Zip | 96951-1249
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 670-532-9461
-----------------------------------------------------
Fax | 670-532-0698
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | 2161
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------