Provider Demographics
NPI:1972184877
Name:MASHBURN, KAELA (PA-C)
Entity Type:Individual
Prefix:
First Name:KAELA
Middle Name:
Last Name:MASHBURN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KAELA
Other - Middle Name:
Other - Last Name:LESKOVAR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:95 S PAGOSA BLVD
Mailing Address - Street 2:
Mailing Address - City:PAGOSA SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:81147-8329
Mailing Address - Country:US
Mailing Address - Phone:970-731-3700
Mailing Address - Fax:970-731-0511
Practice Address - Street 1:95 S PAGOSA BLVD
Practice Address - Street 2:
Practice Address - City:PAGOSA SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:81147-8329
Practice Address - Country:US
Practice Address - Phone:970-731-3700
Practice Address - Fax:970-731-0511
Is Sole Proprietor?:No
Enumeration Date:2021-04-21
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA.0007112363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical