Provider Demographics
NPI:1760991459
Name:PAVLACKA, AUBREY DANELL (PA-C)
Entity Type:Individual
Prefix:
First Name:AUBREY
Middle Name:DANELL
Last Name:PAVLACKA
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 1:1000 RUSH DR
Mailing Address - Street 2:
Mailing Address - City:SALIDA
Mailing Address - State:CO
Mailing Address - Zip Code:81201-9627
Mailing Address - Country:US
Mailing Address - Phone:316-993-9833
Mailing Address - Fax:
Practice Address - Street 1:1000 RUSH DR
Practice Address - Street 2:
Practice Address - City:SALIDA
Practice Address - State:CO
Practice Address - Zip Code:81201-9627
Practice Address - Country:US
Practice Address - Phone:719-530-2200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-25
Last Update Date:2021-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0005156363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant