Provider Demographics
NPI:1376219501
Name:JOHANNESSEN, MARTE ELLA (PA)
Entity Type:Individual
Prefix:
First Name:MARTE
Middle Name:ELLA
Last Name:JOHANNESSEN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6652 GREEN RIVER DR UNIT H
Mailing Address - Street 2:
Mailing Address - City:HIGHLANDS RANCH
Mailing Address - State:CO
Mailing Address - Zip Code:80130-6796
Mailing Address - Country:US
Mailing Address - Phone:413-824-1556
Mailing Address - Fax:
Practice Address - Street 1:8006 E ARAPAHOE RD
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80112-6815
Practice Address - Country:US
Practice Address - Phone:303-220-9168
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-18
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA.0006871363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant