Provider Demographics
NPI:1174779250
Name:HUMISTON, JON ROBERT (PA)
Entity type:Individual
Prefix:
First Name:JON
Middle Name:ROBERT
Last Name:HUMISTON
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 1:6675 HOLMES RD STE 400&425
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64131-1150
Mailing Address - Country:US
Mailing Address - Phone:816-276-7410
Mailing Address - Fax:816-276-7450
Practice Address - Street 1:6675 HOLMES RD STE 400&425
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64131-1150
Practice Address - Country:US
Practice Address - Phone:816-276-7410
Practice Address - Fax:816-276-7450
Is Sole Proprietor?:No
Enumeration Date:2008-08-08
Last Update Date:2022-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018002356363A00000X
KST-02190363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF400199404Medicare PIN