Provider Demographics
NPI:1629565171
Name:LATHAM, ALEX (PA-C)
Entity Type:Individual
Prefix:MR
First Name:ALEX
Middle Name:
Last Name:LATHAM
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 1:17680 ARROWWOOD DR
Mailing Address - Street 2:
Mailing Address - City:MONUMENT
Mailing Address - State:CO
Mailing Address - Zip Code:80132-8433
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8101 E LOWRY BLVD
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80230-7196
Practice Address - Country:US
Practice Address - Phone:303-344-9090
Practice Address - Fax:303-344-1922
Is Sole Proprietor?:No
Enumeration Date:2018-04-20
Last Update Date:2018-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
COPA.0005231363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant