Provider Demographics
NPI:1851673495
Name:MOMPELLIER, CARLY ANN (PA-C)
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:ANN
Last Name:MOMPELLIER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2695 ROCKY MOUNTAIN AVE STE 150
Mailing Address - Street 2:
Mailing Address - City:LOVELAND
Mailing Address - State:CO
Mailing Address - Zip Code:80538-9071
Mailing Address - Country:US
Mailing Address - Phone:970-624-4451
Mailing Address - Fax:970-490-4173
Practice Address - Street 1:2450 S PEORIA ST STE 245
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80014-5475
Practice Address - Country:US
Practice Address - Phone:303-752-7732
Practice Address - Fax:720-848-9112
Is Sole Proprietor?:No
Enumeration Date:2011-09-09
Last Update Date:2023-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015053363A00000X
COPA.0006278363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000186067Medicaid