Provider Demographics
NPI:1104822162
Name:PELLAND, RAYMOND J (PA-C)
Entity Type:Individual
Prefix:MR
First Name:RAYMOND
Middle Name:J
Last Name:PELLAND
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45606 W US HIGHWAY 50
Mailing Address - Street 2:
Mailing Address - City:CANON CITY
Mailing Address - State:CO
Mailing Address - Zip Code:81212-8249
Mailing Address - Country:US
Mailing Address - Phone:719-276-9393
Mailing Address - Fax:
Practice Address - Street 1:1335 PHAY AVE
Practice Address - Street 2:STE D
Practice Address - City:CANON CITY
Practice Address - State:CO
Practice Address - Zip Code:81212-2349
Practice Address - Country:US
Practice Address - Phone:719-269-8820
Practice Address - Fax:719-204-0230
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2086363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant