Provider Demographics
NPI:1710084264
Name:PAGE, KEVIN C (PA)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:C
Last Name:PAGE
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:PO BOX 1024
Mailing Address - Street 2:
Mailing Address - City:EASTLAKE
Mailing Address - State:CO
Mailing Address - Zip Code:80614-1024
Mailing Address - Country:US
Mailing Address - Phone:720-323-9778
Mailing Address - Fax:
Practice Address - Street 1:1000 W SOUTH BOULDER RD
Practice Address - Street 2:SUITE 214
Practice Address - City:LAFAYETTE
Practice Address - State:CO
Practice Address - Zip Code:80026-2752
Practice Address - Country:US
Practice Address - Phone:720-323-9778
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-19
Last Update Date:2013-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1185363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
COCOA101833Medicare PIN