Provider Demographics
NPI:1629480983
Name:JOHNSON, ERIN HEATHER
Entity Type:Individual
Prefix:
First Name:ERIN
Middle Name:HEATHER
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ERIN
Other - Middle Name:HEATHER
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 12330
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30914-2330
Mailing Address - Country:US
Mailing Address - Phone:706-863-9595
Mailing Address - Fax:
Practice Address - Street 1:601 E HAMPDEN AVE STE 310
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80113-2769
Practice Address - Country:US
Practice Address - Phone:855-863-9595
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-21
Last Update Date:2023-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0003943363A00000X, 363AS0400X
COPA.0003943363AM0700X, 363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO96235543Medicaid
CO374844YL2GMedicare PIN