Provider Demographics
NPI:1508812470
Name:JOHNSON, ELARY VIOLETT (PA-C)
Entity Type:Individual
Prefix:MS
First Name:ELARY
Middle Name:VIOLETT
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:ELARY
Other - Middle Name:K
Other - Last Name:VIOLETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:7610 N UNION BLVD
Mailing Address - Street 2:STE 150
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80920-3800
Mailing Address - Country:US
Mailing Address - Phone:719-434-8810
Mailing Address - Fax:519-805-2164
Practice Address - Street 1:6660 DELMONICO DR
Practice Address - Street 2:SUITE D-455
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80919-1899
Practice Address - Country:US
Practice Address - Phone:719-641-7999
Practice Address - Fax:844-511-6950
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2020-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1628363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO70929319Medicaid
COP78906Medicare UPIN
CO805679Medicare PIN
CO805679Medicare PIN