Provider Demographics
NPI:1942251228
Name:DIREZZA, CANDACE LILLIAN (PAC)
Entity Type:Individual
Prefix:MRS
First Name:CANDACE
Middle Name:LILLIAN
Last Name:DIREZZA
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9841 UPHAM DR
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:CO
Mailing Address - Zip Code:80021-4070
Mailing Address - Country:US
Mailing Address - Phone:303-422-4369
Mailing Address - Fax:
Practice Address - Street 1:3555 LUTHERAN PKWY STE 200
Practice Address - Street 2:
Practice Address - City:WHEAT RIDGE
Practice Address - State:CO
Practice Address - Zip Code:80033-6027
Practice Address - Country:US
Practice Address - Phone:720-284-3700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2013-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COCO 1444363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO45274819Medicaid
CO45274819Medicaid
C448168Medicare PIN