Provider Demographics
NPI:1972574002
Name:DOETSCH, AMANDA MASEK (PA-C)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:MASEK
Last Name:DOETSCH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:MASEK
Other - Last Name:DOETSCH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA
Mailing Address - Street 1:777 29TH ST STE 301
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80303-2316
Mailing Address - Country:US
Mailing Address - Phone:303-440-8243
Mailing Address - Fax:303-440-0292
Practice Address - Street 1:777 29TH ST STE 301
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80303-2316
Practice Address - Country:US
Practice Address - Phone:303-440-8243
Practice Address - Fax:303-440-0292
Is Sole Proprietor?:No
Enumeration Date:2006-01-27
Last Update Date:2023-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2164363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
COP00728529OtherRAILROAD MEDICARE PIN
CO77656369Medicaid
COQ56939Medicare UPIN
COCO304394Medicare PIN
CO77656369Medicaid