Basic Information
| Provider Information | |||||||||
| NPI: | 1578748505 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MWANGI | ||||||||
| FirstName: | JOHNSON | ||||||||
| MiddleName: | N | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5414 S BROADWAY AVE | ||||||||
| Address2: | |||||||||
| City: | TYLER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 757031335 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9035811601 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3205 N ACADEMY BLVD STE 100 | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809175147 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7196325700 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/09/2008 | ||||||||
| LastUpdateDate: | 08/15/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA011035 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AM0700X | PA011035 | TX | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 44155301 | 05 | CO | MEDICAID |