Provider Demographics
NPI:1841234515
Name:JOHNSON, TIM R (PAC)
Entity Type:Individual
Prefix:
First Name:TIM
Middle Name:R
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8101 E LOWRY BLVD STE 120
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80230-7195
Mailing Address - Country:US
Mailing Address - Phone:720-865-6072
Mailing Address - Fax:720-865-6072
Practice Address - Street 1:145 INVERNESS DR E STE 220
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80112-5172
Practice Address - Country:US
Practice Address - Phone:303-699-7325
Practice Address - Fax:303-699-5486
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2022-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA.0002277363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO94559813Medicaid
CO806339Medicare PIN