Provider Demographics
NPI:1912459637
Name:JAMISON, MITCHELL (PA-C)
Entity Type:Individual
Prefix:
First Name:MITCHELL
Middle Name:
Last Name:JAMISON
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 1:2121 E HARMONY RD UNIT 100
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80528-3401
Mailing Address - Country:US
Mailing Address - Phone:970-221-1000
Mailing Address - Fax:970-297-6844
Practice Address - Street 1:2121 E HARMONY RD UNIT 100
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80528-3401
Practice Address - Country:US
Practice Address - Phone:970-221-1000
Practice Address - Fax:970-297-6844
Is Sole Proprietor?:No
Enumeration Date:2016-10-28
Last Update Date:2021-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC5-0001095363AM0700X
COPA.0005779363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000175013Medicaid