Provider Demographics
NPI:1871503540
Name:JOHNSEN, JAMES
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:
Last Name:JOHNSEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 E PRIMROSE ST
Mailing Address - Street 2:SUITE 520
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65807-5154
Mailing Address - Country:US
Mailing Address - Phone:417-269-4550
Mailing Address - Fax:
Practice Address - Street 1:1000 E PRIMROSE ST
Practice Address - Street 2:SUITE 520
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-5154
Practice Address - Country:US
Practice Address - Phone:417-269-4550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2022-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO074650367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO910898402Medicaid