Provider Demographics
NPI:1003248279
Name:DOHERTY, FELICIA MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:FELICIA
Middle Name:MARIE
Last Name:DOHERTY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:FELICIA
Other - Middle Name:MARIE
Other - Last Name:HUTCHISON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:2930 11TH AVE
Mailing Address - Street 2:
Mailing Address - City:EVANS
Mailing Address - State:CO
Mailing Address - Zip Code:80620-1011
Mailing Address - Country:US
Mailing Address - Phone:970-353-9403
Mailing Address - Fax:970-350-4692
Practice Address - Street 1:2930 11TH AVE
Practice Address - Street 2:
Practice Address - City:EVANS
Practice Address - State:CO
Practice Address - Zip Code:80620-1011
Practice Address - Country:US
Practice Address - Phone:970-353-9403
Practice Address - Fax:970-350-4692
Is Sole Proprietor?:No
Enumeration Date:2013-07-30
Last Update Date:2016-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO3748363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO3748OtherSTATE LICENSE
CO57474737Medicaid