Provider Demographics
NPI:1639452618
Name:JOHANSEN, ROBERT (PA-C)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:
Last Name:JOHANSEN
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 1:529 JASMINE ST
Mailing Address - Street 2:
Mailing Address - City:OMAK
Mailing Address - State:WA
Mailing Address - Zip Code:98841-9589
Mailing Address - Country:US
Mailing Address - Phone:509-826-1600
Mailing Address - Fax:
Practice Address - Street 1:529 JASMINE ST
Practice Address - Street 2:
Practice Address - City:OMAK
Practice Address - State:WA
Practice Address - Zip Code:98841-9589
Practice Address - Country:US
Practice Address - Phone:509-826-1600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-26
Last Update Date:2015-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA60248541363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1639452618Medicaid
WA1639452618Medicaid
WAG8919954Medicare PIN
WA1639452618Medicaid