Provider Demographics
NPI:1922162700
Name:BERTZ, KRISTA MCCUNE (PA-C)
Entity Type:Individual
Prefix:
First Name:KRISTA
Middle Name:MCCUNE
Last Name:BERTZ
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KRISTA
Other - Middle Name:MCCUNE
Other - Last Name:ALTMIN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA-C
Mailing Address - Street 1:10350 E DAKOTA AVE
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80247-1314
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10240 PARK MEADOWS DR
Practice Address - Street 2:
Practice Address - City:LONE TREE
Practice Address - State:CO
Practice Address - Zip Code:80124-5425
Practice Address - Country:US
Practice Address - Phone:303-338-4545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2021-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA-2359363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO22269OtherKAISER COMMERCIAL NUMBER
CO13150821Medicaid
CO13150821Medicaid