Provider Demographics
NPI:1205970365
Name:JOHNSON, LARRY DEAN (PA)
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:DEAN
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PA
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 802843
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64180-2843
Mailing Address - Country:US
Mailing Address - Phone:417-269-7241
Mailing Address - Fax:417-269-7567
Practice Address - Street 1:525 BRANSON LANDING BLVD
Practice Address - Street 2:
Practice Address - City:BRANSON
Practice Address - State:MO
Practice Address - Zip Code:65616-2052
Practice Address - Country:US
Practice Address - Phone:417-348-8646
Practice Address - Fax:417-335-7529
Is Sole Proprietor?:No
Enumeration Date:2007-02-20
Last Update Date:2021-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPA-263363A00000X
MO2018044339363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
84690OtherAR BLUE CROSS
AR31775YJC8Medicare PIN