Provider Demographics
NPI:1417520024
Name:FOCAZIO, MATTHEW (PA-C)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:FOCAZIO
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 1:3329 E BAYAUD AVE APT 509
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80209-3342
Mailing Address - Country:US
Mailing Address - Phone:386-290-7028
Mailing Address - Fax:
Practice Address - Street 1:1325 S COLORADO BLVD STE 509
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80222-3320
Practice Address - Country:US
Practice Address - Phone:303-321-0123
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-21
Last Update Date:2021-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA.0006767363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
COPA.0006767OtherSTATE OF COLORADO BOARD OF MEDICINE