Provider Demographics
NPI:1205911328
Name:JOHNSON, KATHRYN MANDELBAUM (PA-C)
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:MANDELBAUM
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 1:345 MAXWELL AVE
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80304-3972
Mailing Address - Country:US
Mailing Address - Phone:303-544-5783
Mailing Address - Fax:303-441-2388
Practice Address - Street 1:2575 SPRUCE ST
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80302-3806
Practice Address - Country:US
Practice Address - Phone:303-449-3594
Practice Address - Fax:303-449-3112
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2012-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO3470363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical