Provider Demographics
NPI:1437573508
Name:JOHNSON, KENT ALAN (NP)
Entity type:Individual
Prefix:
First Name:KENT
Middle Name:ALAN
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:306 MAIN ST # 619
Mailing Address - Street 2:
Mailing Address - City:CANON CITY
Mailing Address - State:CO
Mailing Address - Zip Code:81212-3732
Mailing Address - Country:US
Mailing Address - Phone:918-344-2128
Mailing Address - Fax:918-642-5639
Practice Address - Street 1:4400 N LINCOLN BLVD
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73105-5104
Practice Address - Country:US
Practice Address - Phone:918-344-2128
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-10
Last Update Date:2024-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COC.RXN.0100341-C-NP363LP0808X
OK86602363LP0808X
COC-APN.0100511-C-NP363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200528420AMedicaid
OK344359YRHZOtherMEDICARE PTAN