Provider Demographics
NPI:1306193727
Name:JANSEN, NICK (PA-C)
Entity Type:Individual
Prefix:
First Name:NICK
Middle Name:
Last Name:JANSEN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31870 E STATE HIGHWAY 51
Mailing Address - Street 2:
Mailing Address - City:COWETA
Mailing Address - State:OK
Mailing Address - Zip Code:74429-7900
Mailing Address - Country:US
Mailing Address - Phone:918-279-3200
Mailing Address - Fax:918-279-1101
Practice Address - Street 1:31870 E STATE HIGHWAY 51
Practice Address - Street 2:
Practice Address - City:COWETA
Practice Address - State:OK
Practice Address - Zip Code:74429-7900
Practice Address - Country:US
Practice Address - Phone:918-279-3200
Practice Address - Fax:918-279-1101
Is Sole Proprietor?:No
Enumeration Date:2012-08-06
Last Update Date:2022-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OK2161363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program