Provider Demographics
NPI:1275590598
Name:POWELL, LORETTA C (PAC)
Entity Type:Individual
Prefix:MRS
First Name:LORETTA
Middle Name:C
Last Name:POWELL
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:820 1ST STREET
Mailing Address - Street 2:
Mailing Address - City:LIMON
Mailing Address - State:CO
Mailing Address - Zip Code:80828-1120
Mailing Address - Country:US
Mailing Address - Phone:719-775-2367
Mailing Address - Fax:719-775-2365
Practice Address - Street 1:820 1ST STREET
Practice Address - Street 2:
Practice Address - City:LIMON
Practice Address - State:CO
Practice Address - Zip Code:80828-1120
Practice Address - Country:US
Practice Address - Phone:719-775-2367
Practice Address - Fax:719-775-2365
Is Sole Proprietor?:No
Enumeration Date:2006-04-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2294363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO2294OtherSTATE LICENSE
S66694Medicare UPIN
CO2294OtherSTATE LICENSE