Basic Information
| Provider Information | |||||||||
| NPI: | 1801845631 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | STANLEY | ||||||||
| MiddleName: | ROBIN | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2 S CASCADE AVE | ||||||||
| Address2: | STE 140 | ||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809031624 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195382900 | ||||||||
| FaxNumber: | 7195382987 | ||||||||
| Practice Location | |||||||||
| Address1: | 2610 TENDERFOOT HILL ST | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809063981 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7196325309 | ||||||||
| FaxNumber: | 7194752042 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/09/2006 | ||||||||
| LastUpdateDate: | 04/27/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA0000080 | CO | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 970017046 | 01 | CO | RR MEDICARE | OTHER | 07000805 | 05 | CO | MEDICAID |