Basic Information
| Provider Information | |||||||||
| NPI: | 1982945788 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | WAYNE | ||||||||
| MiddleName: | WILLIAM | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4900 S MONACO ST | ||||||||
| Address2: | #210 | ||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802373486 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3037892663 | ||||||||
| FaxNumber: | 3037884871 | ||||||||
| Practice Location | |||||||||
| Address1: | 799 E HAMPDEN AVE | ||||||||
| Address2: | #400 | ||||||||
| City: | ENGLEWOOD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801132700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3037892663 | ||||||||
| FaxNumber: | 3037884871 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/05/2013 | ||||||||
| LastUpdateDate: | 01/13/2022 | ||||||||
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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 | 243 | CO | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 201076740A | 05 | KS | MEDICAID | 82603219 | 05 | CO | MEDICAID |