Provider Demographics
NPI:1376191569
Name:JOHNSON, JEREMY DUANE (PA-C)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:DUANE
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:715 S 9TH ST
Mailing Address - Street 2:
Mailing Address - City:CANON CITY
Mailing Address - State:CO
Mailing Address - Zip Code:81212-4911
Mailing Address - Country:US
Mailing Address - Phone:719-268-8820
Mailing Address - Fax:
Practice Address - Street 1:9320 GRAND CORDERA PKWY STE 100
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80924-7004
Practice Address - Country:US
Practice Address - Phone:719-282-6337
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-30
Last Update Date:2021-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA.0005940363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000177362Medicaid