Basic Information
| Provider Information | |||||||||
| NPI: | 1205911328 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | KATHRYN | ||||||||
| MiddleName: | MANDELBAUM | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 345 MAXWELL AVE | ||||||||
| Address2: | |||||||||
| City: | BOULDER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 803043972 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3035445783 | ||||||||
| FaxNumber: | 3034412388 | ||||||||
| Practice Location | |||||||||
| Address1: | 2575 SPRUCE ST | ||||||||
| Address2: | |||||||||
| City: | BOULDER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 803023806 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3034493594 | ||||||||
| FaxNumber: | 3034493112 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/26/2006 | ||||||||
| LastUpdateDate: | 10/08/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 3470 | CO | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.