Healthcare Provider Details

I. General information

NPI: 1558033985
Provider Name (Legal Business Name): AMY JOHNSON PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2021
Last Update Date: 10/04/2021
Certification Date: 10/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 MIDLAND AVE UNIT 230
GLENWOOD SPRINGS CO
81601-9802
US

IV. Provider business mailing address

PO BOX 2601
GLENWOOD SPRINGS CO
81602-2601
US

V. Phone/Fax

Practice location:
  • Phone: 970-947-0600
  • Fax:
Mailing address:
  • Phone: 970-947-0600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA-0001234
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: