Provider Demographics
NPI:1982682787
Name:PATTERSON, JACOB F
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:F
Last Name:PATTERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 310
Mailing Address - Street 2:
Mailing Address - City:CANON CITY
Mailing Address - State:CO
Mailing Address - Zip Code:81215-0310
Mailing Address - Country:US
Mailing Address - Phone:719-275-0687
Mailing Address - Fax:719-275-0690
Practice Address - Street 1:933 SELL AVE
Practice Address - Street 2:SUITE A
Practice Address - City:CANON CITY
Practice Address - State:CO
Practice Address - Zip Code:81212-4900
Practice Address - Country:US
Practice Address - Phone:719-275-0687
Practice Address - Fax:719-275-0690
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-03
Last Update Date:2010-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO30868207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
142165200OtherUS DEPT OF LABOR
CO33886OtherANTHEM BLUECROSSBLUE SHIE
841171832OtherTRICARE FOR LIFE WPS
5502AMPR006855OtherANTHEM BLUECROSSBLUESHIEL
CO01308683Medicaid
COP00262003OtherRAILROAD MEDICARE
COCOB4861Medicare PIN
5502AMPR006855OtherANTHEM BLUECROSSBLUESHIEL
COP00262003OtherRAILROAD MEDICARE
841171832OtherTRICARE FOR LIFE WPS