Provider Demographics
NPI:1275518540
Name:ROCKWELL, DETERRI DAWN
Entity Type:Individual
Prefix:
First Name:DETERRI
Middle Name:DAWN
Last Name:ROCKWELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DETERRI
Other - Middle Name:
Other - Last Name:ROCKWELL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA
Mailing Address - Street 1:P.O. BOX 173862
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80217-3862
Mailing Address - Country:US
Mailing Address - Phone:303-306-7783
Mailing Address - Fax:303-306-7753
Practice Address - Street 1:9191 GRANT ST.
Practice Address - Street 2:
Practice Address - City:THORNTON
Practice Address - State:CO
Practice Address - Zip Code:80229-8812
Practice Address - Country:US
Practice Address - Phone:303-450-4482
Practice Address - Fax:303-306-7753
Is Sole Proprietor?:No
Enumeration Date:2005-12-09
Last Update Date:2015-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1024363A00000X
COPA.0001024363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO84886714Medicaid
CO84886714Medicaid
COCO306500Medicare PIN