Provider Demographics
NPI:1942432760
Name:DEITEMEYER, AMY (PA-C)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:DEITEMEYER
Suffix:
Gender:F
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 1:110 E ROUTT AVE
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81004-2117
Mailing Address - Country:US
Mailing Address - Phone:719-543-8718
Mailing Address - Fax:719-585-3042
Practice Address - Street 1:300 COLORADO AVE
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81004-2006
Practice Address - Country:US
Practice Address - Phone:719-543-8718
Practice Address - Fax:719-296-8648
Is Sole Proprietor?:No
Enumeration Date:2009-08-12
Last Update Date:2014-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2814363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO78120519Medicaid