Healthcare Provider Details

I. General information

NPI: 1700033156
Provider Name (Legal Business Name): JOHN K CLAYSHULTE III PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/27/2008
Last Update Date: 02/03/2026
Certification Date: 02/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5700 N ELIZABETH ST
PUEBLO CO
81008-2166
US

IV. Provider business mailing address

9348 GRAND CORDERA PKWY STE 160
COLORADO SPRINGS CO
80924-7023
US

V. Phone/Fax

Practice location:
  • Phone: 719-355-1585
  • Fax: 719-623-2983
Mailing address:
  • Phone: 719-355-1585
  • Fax: 719-623-2983

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number60632876
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA.0008465
License Number StateCO
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2014-0058
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: