Provider Demographics
NPI:1124001649
Name:DISTEFANO, BROOKE (PA)
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:
Last Name:DISTEFANO
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7800 E ORCHARD RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:GREENWOOD VILLAGE
Mailing Address - State:CO
Mailing Address - Zip Code:80111-2583
Mailing Address - Country:US
Mailing Address - Phone:303-697-7463
Mailing Address - Fax:303-783-1200
Practice Address - Street 1:7800 E ORCHARD RD
Practice Address - Street 2:SUITE 100
Practice Address - City:GREENWOOD VILLAGE
Practice Address - State:CO
Practice Address - Zip Code:80111-2583
Practice Address - Country:US
Practice Address - Phone:303-697-7463
Practice Address - Fax:303-783-1200
Is Sole Proprietor?:No
Enumeration Date:2005-11-29
Last Update Date:2012-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AM0700X
CO3413363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8B7856Medicare ID - Type Unspecified