Provider Demographics
NPI:1982945788
Name:JOHNSON, WAYNE WILLIAM (PA)
Entity Type:Individual
Prefix:
First Name:WAYNE
Middle Name:WILLIAM
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4900 S MONACO ST
Mailing Address - Street 2:#210
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80237-3486
Mailing Address - Country:US
Mailing Address - Phone:303-789-2663
Mailing Address - Fax:303-788-4871
Practice Address - Street 1:799 E HAMPDEN AVE
Practice Address - Street 2:#400
Practice Address - City:ENGLEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80113-2700
Practice Address - Country:US
Practice Address - Phone:303-789-2663
Practice Address - Fax:303-788-4871
Is Sole Proprietor?:No
Enumeration Date:2013-03-05
Last Update Date:2022-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO243363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS201076740AMedicaid
CO82603219Medicaid
KSKA3266001Medicare PIN
KS201076740AMedicaid
COP01565268Medicare UPIN