Provider Demographics
NPI:1275698904
Name:ANTONELLI, LARA M (PA)
Entity Type:Individual
Prefix:
First Name:LARA
Middle Name:M
Last Name:ANTONELLI
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 1:1107 S LEMAY AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80524-3959
Mailing Address - Country:US
Mailing Address - Phone:970-484-1757
Mailing Address - Fax:970-484-9924
Practice Address - Street 1:1107 S LEMAY AVE STE 200
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80524-3959
Practice Address - Country:US
Practice Address - Phone:970-484-1757
Practice Address - Fax:970-484-9924
Is Sole Proprietor?:No
Enumeration Date:2006-12-22
Last Update Date:2022-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA 1669363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO848020573009OtherROCKY MTN HMO
COAN660037OtherBCBS
CO55828876Medicaid
CO848020573009OtherROCKY MTN HMO
CO301039Medicare PIN