Provider Demographics
NPI:1972588358
Name:PUCKETT, SUSAN (PA)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:PUCKETT
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2750 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80304-3573
Mailing Address - Country:US
Mailing Address - Phone:303-440-3073
Mailing Address - Fax:303-440-3170
Practice Address - Street 1:2750 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80304-3573
Practice Address - Country:US
Practice Address - Phone:303-440-3000
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-08
Last Update Date:2021-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO954363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO12868Medicare ID - Type Unspecified
R08615Medicare UPIN