Provider Demographics
NPI:1356591762
Name:KUPFNER, JOHNATHON D (PA-C)
Entity type:Individual
Prefix:
First Name:JOHNATHON
Middle Name:D
Last Name:KUPFNER
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 1:1584 JACKSON CREEK PARKWAY
Mailing Address - Street 2:STE 120
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80132
Mailing Address - Country:US
Mailing Address - Phone:719-364-9930
Mailing Address - Fax:719-364-9939
Practice Address - Street 1:1584 JACKSON CREEK PARKWAY
Practice Address - Street 2:STE 120
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80132
Practice Address - Country:US
Practice Address - Phone:719-364-9930
Practice Address - Fax:719-364-9939
Is Sole Proprietor?:No
Enumeration Date:2008-09-22
Last Update Date:2016-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA3508363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO48039047Medicaid
CO459521YLB8Medicare UPIN