Provider Demographics
NPI:1710167655
Name:JOHNSON, BRADLEY TODD
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:TODD
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:BRADLEY
Other - Middle Name:
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 17752
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80217-0752
Mailing Address - Country:US
Mailing Address - Phone:303-306-7783
Mailing Address - Fax:303-306-7753
Practice Address - Street 1:1010 THREE SPRINGS BLVD
Practice Address - Street 2:
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81301-8296
Practice Address - Country:US
Practice Address - Phone:303-306-7783
Practice Address - Fax:303-306-7753
Is Sole Proprietor?:No
Enumeration Date:2007-11-08
Last Update Date:2020-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI956363A00000X
CO3202363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO48483885Medicaid
NM35323884Medicaid
CO48483885Medicaid