Provider Demographics
NPI:1467869115
Name:LAGRECA, AMY LYNN (PA-C)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:LYNN
Last Name:LAGRECA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:LYNN
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:2500 E PROSPECT RD
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525-9718
Mailing Address - Country:US
Mailing Address - Phone:970-493-0112
Mailing Address - Fax:970-493-0521
Practice Address - Street 1:2500 E PROSPECT RD
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525-9718
Practice Address - Country:US
Practice Address - Phone:970-493-0112
Practice Address - Fax:970-493-0521
Is Sole Proprietor?:No
Enumeration Date:2014-07-15
Last Update Date:2020-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO4444363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical