Provider Demographics
NPI:1508807041
Name:CHURCHILL, JONATHAN HUGH (PA)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:HUGH
Last Name:CHURCHILL
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10103 RIDGEGATE PKWY STE 306
Mailing Address - Street 2:
Mailing Address - City:LONE TREE
Mailing Address - State:CO
Mailing Address - Zip Code:80124-5525
Mailing Address - Country:US
Mailing Address - Phone:303-586-1839
Mailing Address - Fax:303-225-8130
Practice Address - Street 1:10103 RIDGEGATE PKWY STE 306
Practice Address - Street 2:
Practice Address - City:LONE TREE
Practice Address - State:CO
Practice Address - Zip Code:80124-5525
Practice Address - Country:US
Practice Address - Phone:303-225-8120
Practice Address - Fax:303-225-8130
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2018-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601004763363A00000X
CO0005541363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
N94170003Medicare PIN
0N94170OtherMEDICARE GROUP PROVIDER #