Provider Demographics
NPI:1669575452
Name:CAMPBELL, JOHN ROBERT (PAC)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:ROBERT
Last Name:CAMPBELL
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 1:2880 FOLSOM ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80304-3739
Mailing Address - Country:US
Mailing Address - Phone:303-237-7047
Mailing Address - Fax:303-443-7168
Practice Address - Street 1:2880 FOLSOM ST
Practice Address - Street 2:SUITE 100
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80304-3739
Practice Address - Country:US
Practice Address - Phone:303-327-7047
Practice Address - Fax:303-443-7168
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1215363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
COP00377349OtherRAILROAD MEDICARE
CO52004082Medicaid
CO52004082Medicaid
MC0498267OtherDEA
P03239Medicare UPIN
COC807509Medicare PIN