Provider Demographics
NPI:1245238716
Name:JOHNSON, HERBERT ELTON (PA-C)
Entity type:Individual
Prefix:
First Name:HERBERT
Middle Name:ELTON
Last Name:JOHNSON
Suffix:
Gender:M
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 1:5881 W 16TH ST
Mailing Address - Street 2:SUITE D
Mailing Address - City:GREELEY
Mailing Address - State:CO
Mailing Address - Zip Code:80634-2910
Mailing Address - Country:US
Mailing Address - Phone:970-353-1551
Mailing Address - Fax:970-350-2478
Practice Address - Street 1:5881 W 16TH ST
Practice Address - Street 2:SUITE D
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80634-2910
Practice Address - Country:US
Practice Address - Phone:970-353-1551
Practice Address - Fax:970-350-2478
Is Sole Proprietor?:No
Enumeration Date:2005-07-08
Last Update Date:2016-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO374363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO02706229Medicaid
COC446618Medicare UPIN
P42502Medicare UPIN
CO02706229Medicaid
P42502Medicare Oscar/Certification