Provider Demographics
NPI:1215537220
Name:NISWONGER, JOHN FRANKLIN (AGNP-C)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:FRANKLIN
Last Name:NISWONGER
Suffix:
Gender:M
Credentials:AGNP-C
Other - Prefix:
Other - First Name:JOHNNY
Other - Middle Name:FRANKLIN
Other - Last Name:NISWONGER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:861 CANYON TRL
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MO
Mailing Address - Zip Code:63755-4001
Mailing Address - Country:US
Mailing Address - Phone:573-837-2390
Mailing Address - Fax:
Practice Address - Street 1:861 CANYON TRL
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MO
Practice Address - Zip Code:63755-4001
Practice Address - Country:US
Practice Address - Phone:573-837-2390
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-28
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020034604363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health