Healthcare Provider Details

I. General information

NPI: 1124564331
Provider Name (Legal Business Name): JOHN MAITHA PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2017
Last Update Date: 07/15/2026
Certification Date: 07/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1650 COCHRANE CIR UNIT MEDDAC
FORT CARSON CO
80913-4604
US

IV. Provider business mailing address

1650 COCHRANE CIR UNIT MEDDAC
FORT CARSON CO
80913-4604
US

V. Phone/Fax

Practice location:
  • Phone: 719-526-7000
  • Fax:
Mailing address:
  • Phone: 719-526-7000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1134461
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number25MP00780400
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: