1194769612 NPI number — MARC A JOHNSON PA-C

Table of content: MARC A JOHNSON PA-C (NPI 1194769612)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194769612 NPI number — MARC A JOHNSON PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JOHNSON
Provider First Name:
MARC
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1194769612
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/03/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 673
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MONUMENT
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80132-0673
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
719-650-7994
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
545 3RD ST UNIT 308
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MONUMENT
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80132-4513
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
719-733-3086
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  1915 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 19130538 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com