MEDICARE: MR. JOHN K CLAYSHULTE III PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	60632876	WA
2	363A00000X	Physician Assistant	PA.0008465	CO
3	363A00000X	Physician Assistant	PA2014-0058	NM

General Provider Information

NPI Number	:	1700033156
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JOHN K CLAYSHULTE III PA-C

Provider Business Mailing Address
First Line	:	9348 GRAND CORDERA PKWY STE 160
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80924-7023
Country	:	US
Telephone Number	:	719-355-1585
Fax Number	:	719-623-2983

Provider Business Practice Location Address
First Line	:	5700 N ELIZABETH ST
Second Line	:
City	:	PUEBLO
State	:	CO
Zip	:	81008-2166
Country	:	US
Telephone Number	:	719-355-1585
Fax Number	:	719-623-2983

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/27/2008
Last Update Date	:	02/03/2026

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