Provider Demographics
NPI:1194769612
Name:JOHNSON, MARC A (PA-C)
Entity type:Individual
Prefix:
First Name:MARC
Middle Name:A
Last Name:JOHNSON
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:PO BOX 673
Mailing Address - Street 2:
Mailing Address - City:MONUMENT
Mailing Address - State:CO
Mailing Address - Zip Code:80132-0673
Mailing Address - Country:US
Mailing Address - Phone:719-650-7994
Mailing Address - Fax:
Practice Address - Street 1:545 3RD ST UNIT 308
Practice Address - Street 2:
Practice Address - City:MONUMENT
Practice Address - State:CO
Practice Address - Zip Code:80132-4513
Practice Address - Country:US
Practice Address - Phone:719-733-3086
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2022-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1915363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO19130538Medicaid
CO802193Medicare PIN