Provider Demographics
NPI:1659309631
Name:JOHNSON, DEANNA H (PA-C)
Entity Type:Individual
Prefix:
First Name:DEANNA
Middle Name:H
Last Name:JOHNSON
Suffix:
Gender:F
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 1:2312 N NEVADA AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80907-5302
Mailing Address - Country:US
Mailing Address - Phone:719-473-3272
Mailing Address - Fax:719-389-1191
Practice Address - Street 1:2312 N NEVADA AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80907-5302
Practice Address - Country:US
Practice Address - Phone:719-473-3272
Practice Address - Fax:719-389-1191
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2013-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2243363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO47489057Medicaid
COQ70599Medicare UPIN