Provider Demographics
NPI:1841231230
Name:DOMER, ANDREW RICHARD (PA-C)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:RICHARD
Last Name:DOMER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:8101 E LOWRY BLVD
Mailing Address - Street 2:STE 120
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80230-7195
Mailing Address - Country:US
Mailing Address - Phone:303-806-1998
Mailing Address - Fax:
Practice Address - Street 1:3920 N UNION BLVD STE 330
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80907-4916
Practice Address - Country:US
Practice Address - Phone:719-570-7272
Practice Address - Fax:719-570-9030
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2021-06-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CO4155363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
11561458OtherCAQH NUMBER
11561458OtherCAQH NUMBER