1306846381 NPI number — LUCAS R DERTING PA-C

Table of content: LUCAS R DERTING PA-C (NPI 1306846381)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306846381 NPI number — LUCAS R DERTING PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DERTING
Provider First Name:
LUCAS
Provider Middle Name:
R
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1306846381
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/03/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
03/22/2006
NPI Reactivation Date:
04/11/2006

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 560825
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DENVER
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80256-0825
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
719-595-7580
Provider Business Mailing Address Fax Number:
719-545-0176

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1600 NORTH GRAND AVENUE
Provider Second Line Business Practice Location Address:
SUITE 500
Provider Business Practice Location Address City Name:
PUEBLO
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
81003-2757
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
719-545-0663
Provider Business Practice Location Address Fax Number:
719-595-7903
Provider Enumeration Date:
07/29/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  1080 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363AS0400X , with the licence number: 1080 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 63720345 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".




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