Provider Demographics
NPI:1346335577
Name:HARTMAN, CLINTON LEE (PA-C)
Entity Type:Individual
Prefix:MR
First Name:CLINTON
Middle Name:LEE
Last Name:HARTMAN
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 1:1025 PENNOCK PL STE 121
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80524-3257
Mailing Address - Country:US
Mailing Address - Phone:980-495-8980
Mailing Address - Fax:970-495-8988
Practice Address - Street 1:1025 PENNOCK PL STE 121
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80524-3257
Practice Address - Country:US
Practice Address - Phone:980-495-8980
Practice Address - Fax:970-495-8988
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2020-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA.0000483363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO17208548Medicaid
COCOA106438Medicare PIN