Provider Demographics
NPI:1518940899
Name:SCHACK, ANGIE D (PA-C)
Entity Type:Individual
Prefix:
First Name:ANGIE
Middle Name:D
Last Name:SCHACK
Suffix:
Gender:F
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 1:9777 S YOSEMITE ST
Mailing Address - Street 2:STE. 220
Mailing Address - City:LONETREE
Mailing Address - State:CO
Mailing Address - Zip Code:80124-3191
Mailing Address - Country:US
Mailing Address - Phone:303-699-7325
Mailing Address - Fax:303-699-5486
Practice Address - Street 1:9777 S YOSEMITE ST
Practice Address - Street 2:STE. 220
Practice Address - City:LONETREE
Practice Address - State:CO
Practice Address - Zip Code:80124-3191
Practice Address - Country:US
Practice Address - Phone:303-699-7325
Practice Address - Fax:303-699-5486
Is Sole Proprietor?:No
Enumeration Date:2005-11-21
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA.0001756363AS0400X
CO1756363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO81188544Medicaid
533688Medicare ID - Type Unspecified
CO81188544Medicaid
Q12489Medicare UPIN