Provider Demographics
NPI:1275147845
Name:JOHANSSON, ALISHA
Entity Type:Individual
Prefix:
First Name:ALISHA
Middle Name:
Last Name:JOHANSSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1319 MANITOU AVE
Mailing Address - Street 2:
Mailing Address - City:STEAMBOAT SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80487-4932
Mailing Address - Country:US
Mailing Address - Phone:720-936-8433
Mailing Address - Fax:
Practice Address - Street 1:705 MARKETPLACE PLZ STE 200
Practice Address - Street 2:
Practice Address - City:STEAMBOAT SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80487-1841
Practice Address - Country:US
Practice Address - Phone:970-879-6663
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-01
Last Update Date:2022-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0007418363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty