Provider Demographics
NPI:1164632378
Name:WITTSTOCK, JAMES PATRICK (PA-C)
Entity Type:Individual
Prefix:MR
First Name:JAMES
Middle Name:PATRICK
Last Name:WITTSTOCK
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 1:5919 N COUNTY ROAD 19
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80524-9722
Mailing Address - Country:US
Mailing Address - Phone:970-407-1916
Mailing Address - Fax:
Practice Address - Street 1:2200 O ST
Practice Address - Street 2:
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80631-9503
Practice Address - Country:US
Practice Address - Phone:970-304-6235
Practice Address - Fax:970-304-6241
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1010363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant