Provider Demographics
NPI:1427362516
Name:CLARK, LAURA E (PA-C)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:E
Last Name:CLARK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:KRISTINE
Other - Last Name:ELBERG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:203 S ROLLIE AVE
Mailing Address - Street 2:
Mailing Address - City:FORT LUPTON
Mailing Address - State:CO
Mailing Address - Zip Code:80621-1508
Mailing Address - Country:US
Mailing Address - Phone:303-286-4560
Mailing Address - Fax:303-286-4589
Practice Address - Street 1:1860 E EGBERT ST
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:CO
Practice Address - Zip Code:80601-2475
Practice Address - Country:US
Practice Address - Phone:303-659-4000
Practice Address - Fax:303-659-9306
Is Sole Proprietor?:No
Enumeration Date:2010-07-30
Last Update Date:2013-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA.0003055363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO85357588Medicaid
COCOA102350Medicare PIN