Provider Demographics
NPI:1164753349
Name:CHUKLANOV, ANNA SERGEEVNA (PA)
Entity Type:Individual
Prefix:
First Name:ANNA
Middle Name:SERGEEVNA
Last Name:CHUKLANOV
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 1:1364 S ZENO ST
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80017-4324
Mailing Address - Country:US
Mailing Address - Phone:303-803-2097
Mailing Address - Fax:
Practice Address - Street 1:115 S PARKSIDE DR
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80910-3130
Practice Address - Country:US
Practice Address - Phone:719-635-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-27
Last Update Date:2013-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2855363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical