Provider Demographics
NPI:1548709256
Name:JOHNSON, AMBER (PA)
Entity type:Individual
Prefix:
First Name:AMBER
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:309 E HOSPITAL RD
Mailing Address - Street 2:
Mailing Address - City:EL DORADO SPRINGS
Mailing Address - State:MO
Mailing Address - Zip Code:64744-2021
Mailing Address - Country:US
Mailing Address - Phone:417-876-5851
Mailing Address - Fax:
Practice Address - Street 1:309 E HOSPITAL RD
Practice Address - Street 2:
Practice Address - City:EL DORADO SPRINGS
Practice Address - State:MO
Practice Address - Zip Code:64744-2021
Practice Address - Country:US
Practice Address - Phone:417-876-5851
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-14
Last Update Date:2022-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2017003628363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOPENDINGMedicaid
MOPENDINGMedicare PIN