Provider Demographics
NPI:1790953255
Name:ALLEN, JOHN S (PA)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:S
Last Name:ALLEN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:450B WASHINGTON JACKSON RD
Mailing Address - Street 2:STE 105
Mailing Address - City:EATON
Mailing Address - State:OH
Mailing Address - Zip Code:45320-7601
Mailing Address - Country:US
Mailing Address - Phone:937-456-8350
Mailing Address - Fax:937-456-8351
Practice Address - Street 1:450B WASHINGTON JACKSON RD
Practice Address - Street 2:STE 105
Practice Address - City:EATON
Practice Address - State:OH
Practice Address - Zip Code:45320-7601
Practice Address - Country:US
Practice Address - Phone:937-456-8350
Practice Address - Fax:937-456-8351
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-18
Last Update Date:2019-01-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OH50.002462363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0098696Medicaid
OHH067620Medicare PIN