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:PO BOX 1249
Mailing Address - Street 2:
Mailing Address - City:ROTA
Mailing Address - State:MP
Mailing Address - Zip Code:96951-1249
Mailing Address - Country:US
Mailing Address - Phone:670-532-9461
Mailing Address - Fax:670-532-0698
Practice Address - Street 1:SONGSONG VILLAGE
Practice Address - Street 2:
Practice Address - City:ROTA
Practice Address - State:MP
Practice Address - Zip Code:96951-1249
Practice Address - Country:US
Practice Address - Phone:670-532-9461
Practice Address - Fax:670-532-0698
Is Sole Proprietor?:No
Enumeration Date:2012-08-06
Last Update Date:2025-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2161363AM0700X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program