Provider Demographics
NPI:1699856377
Name:CARCELLA, ANTHONY KYLE
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:KYLE
Last Name:CARCELLA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:ANTHONY
Other - Middle Name:K
Other - Last Name:CARCELLA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 173894
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80217-3894
Mailing Address - Country:US
Mailing Address - Phone:303-306-7783
Mailing Address - Fax:303-306-7753
Practice Address - Street 1:4747 ARAPAHOE AVE
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80303
Practice Address - Country:US
Practice Address - Phone:303-415-7000
Practice Address - Fax:303-306-7753
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2019-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2333363A00000X
COPA.0002333363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
COP00399431OtherRAILROAD MEDICARE
CO84289279Medicaid
CO84289279Medicaid