Provider Demographics
NPI:1801845631
Name:JOHNSON, STANLEY ROBIN (PA)
Entity type:Individual
Prefix:MR
First Name:STANLEY
Middle Name:ROBIN
Last Name:JOHNSON
Suffix:
Gender:
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 35380
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89133-5380
Mailing Address - Country:US
Mailing Address - Phone:719-538-2900
Mailing Address - Fax:719-538-2990
Practice Address - Street 1:2610 TENDERFOOT HILL ST
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80906-3981
Practice Address - Country:US
Practice Address - Phone:719-632-5309
Practice Address - Fax:719-475-2042
Is Sole Proprietor?:No
Enumeration Date:2006-05-09
Last Update Date:2025-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA0000080363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO970017046OtherRR MEDICARE
CO07000805Medicaid
COS34132Medicare UPIN
CO07000805Medicaid