Provider Demographics
NPI:1891714234
Name:JOHNSON, MICHAEL JAMES (PA)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:JAMES
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:445 E CHEYENNE MOUNTAIN BLVD STE C PMB 406
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80906-4570
Mailing Address - Country:US
Mailing Address - Phone:719-538-8100
Mailing Address - Fax:719-538-8003
Practice Address - Street 1:1008 MINNEQUA AVE
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81004-3733
Practice Address - Country:US
Practice Address - Phone:719-560-5656
Practice Address - Fax:719-560-4715
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO595363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO970016858OtherRAILROAD MEDICARE
CO07005952Medicaid
CO07005952Medicaid
COS75873Medicare UPIN
CO07005952Medicaid