Provider Demographics
NPI:1306846381
Name:DERTING, LUCAS R (PA-C)
Entity Type:Individual
Prefix:
First Name:LUCAS
Middle Name:R
Last Name:DERTING
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:PO BOX 560825
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80256-0825
Mailing Address - Country:US
Mailing Address - Phone:719-595-7580
Mailing Address - Fax:719-545-0176
Practice Address - Street 1:1600 NORTH GRAND AVENUE
Practice Address - Street 2:SUITE 500
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81003-2757
Practice Address - Country:US
Practice Address - Phone:719-545-0663
Practice Address - Fax:719-595-7903
Is Sole Proprietor?:No
Enumeration Date:2005-07-29
Last Update Date:2016-11-03
Deactivation Date:2006-03-22
Deactivation Code:
Reactivation Date:2006-04-11
Provider Licenses
StateLicense IDTaxonomies
CO1080363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO63720345Medicaid
CO63720345Medicaid