Basic Information
| Provider Information | |||||||||
| NPI: | 1619933140 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSTON | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2305 SOUTH 65 HIGHWAY | ||||||||
| Address2: | |||||||||
| City: | MARSHALL | ||||||||
| State: | MO | ||||||||
| PostalCode: | 653403702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6608687431 | ||||||||
| FaxNumber: | 6608869001 | ||||||||
| Practice Location | |||||||||
| Address1: | 2305 SOUTH 65 HIGHWAY | ||||||||
| Address2: | |||||||||
| City: | MARSHALL | ||||||||
| State: | MO | ||||||||
| PostalCode: | 653403702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6608867431 | ||||||||
| FaxNumber: | 6608869001 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/24/2006 | ||||||||
| LastUpdateDate: | 08/11/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 096914 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 540568508 | 05 | MO | MEDICAID | 010568509 | 05 | MO | MEDICAID | 595956202 | 05 | MO | MEDICAID | 33415014 | 01 | BCBS | OTHER | 429090905 | 05 | MO | MEDICAID | 33415034 | 01 | BCBS | OTHER |