Healthcare Provider Details

I. General information

NPI: 1679413470
Provider Name (Legal Business Name): DYLIN L JOHNSON
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/31/2026
Last Update Date: 06/16/2026
Certification Date: 06/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2479 E COLORADO BLVD
SPEARFISH SD
57783-3204
US

IV. Provider business mailing address

1212 RAINTREE DR UNIT G136
FORT COLLINS CO
80526-1974
US

V. Phone/Fax

Practice location:
  • Phone: 605-644-4460
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: