MEDICARE: ETHAN JOHNSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant

General Provider Information

NPI Number	:	1619827227
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ETHAN JOHNSON

Provider Business Mailing Address
First Line	:	1123 E MEADOWLARK ST
Second Line	:
City	:	SPRINGFIELD
State	:	MO
Zip	:	65810-2961
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1235 E CHEROKEE ST
Second Line	:
City	:	SPRINGFIELD
State	:	MO
Zip	:	65804-2203
Country	:	US
Telephone Number	:	417-496-0724
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/02/2026
Last Update Date	:	02/02/2026

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Directions to “ ETHAN JOHNSON ” Practice Location

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