Provider Demographics
NPI:1760553150
Name:JOHNSON, KRISTINA A (PA-C)
Entity Type:Individual
Prefix:MS
First Name:KRISTINA
Middle Name:A
Last Name:JOHNSON
Suffix:
Gender:F
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 1:1215 DUFF AVE
Mailing Address - Street 2:
Mailing Address - City:AMES
Mailing Address - State:IA
Mailing Address - Zip Code:50010-5469
Mailing Address - Country:US
Mailing Address - Phone:515-235-9440
Mailing Address - Fax:
Practice Address - Street 1:3600 LINCOLN WAY
Practice Address - Street 2:
Practice Address - City:AMES
Practice Address - State:IA
Practice Address - Zip Code:50014-7595
Practice Address - Country:US
Practice Address - Phone:152-394-0775
Practice Address - Fax:515-239-4758
Is Sole Proprietor?:No
Enumeration Date:2006-11-10
Last Update Date:2023-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA001768363AM0700X, 363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAP00374217OtherRR MEDICARE
IA35349OtherWELLMARK
IA8123083Medicaid
IAI18712Medicare PIN
IA35349OtherWELLMARK