Provider Demographics
NPI:1609123595
Name:MOLENCAMP, AARON (PA)
Entity Type:Individual
Prefix:
First Name:AARON
Middle Name:
Last Name:MOLENCAMP
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3676 PARKER BLVD
Mailing Address - Street 2:SUITE NUMBER 390
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81008-2210
Mailing Address - Country:US
Mailing Address - Phone:719-595-7780
Mailing Address - Fax:719-595-7789
Practice Address - Street 1:3676 PARKER BLVD
Practice Address - Street 2:SUITE NUMBER 390
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81008-2210
Practice Address - Country:US
Practice Address - Phone:719-595-7780
Practice Address - Fax:719-595-7789
Is Sole Proprietor?:No
Enumeration Date:2012-08-09
Last Update Date:2014-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0003510363A00000X
CO3510363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO06707718Medicaid
CO06707718Medicaid