Provider Demographics
NPI:1992197974
Name:FAN, ELIZABETH (MS, PA-C)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:FAN
Suffix:
Gender:F
Credentials:MS, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80206-2761
Mailing Address - Country:US
Mailing Address - Phone:303-388-4461
Mailing Address - Fax:303-398-1211
Practice Address - Street 1:1400 JACKSON ST
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80206-2761
Practice Address - Country:US
Practice Address - Phone:303-388-4461
Practice Address - Fax:303-398-1211
Is Sole Proprietor?:No
Enumeration Date:2015-02-27
Last Update Date:2021-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA.0004030363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO404481YLSHOtherMEDICARE PTAN
CO1992197974Medicaid
CO28759311Medicaid