Provider Demographics
NPI:1770255697
Name:BERMUDEZ, JUANCARLOS (PA-C)
Entity Type:Individual
Prefix:
First Name:JUANCARLOS
Middle Name:
Last Name:BERMUDEZ
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 1:1550 E NIAGARA RD
Mailing Address - Street 2:
Mailing Address - City:MONTROSE
Mailing Address - State:CO
Mailing Address - Zip Code:81401-5027
Mailing Address - Country:US
Mailing Address - Phone:970-497-4921
Mailing Address - Fax:855-855-4482
Practice Address - Street 1:1550 E NIAGARA RD
Practice Address - Street 2:
Practice Address - City:MONTROSE
Practice Address - State:CO
Practice Address - Zip Code:81401-5027
Practice Address - Country:US
Practice Address - Phone:970-497-4921
Practice Address - Fax:855-855-4482
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-29
Last Update Date:2023-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA.0007949363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant