Provider Demographics
NPI:1184761991
Name:WILTIN, KAREN LUEBCKE (PA-C)
Entity type:Individual
Prefix:
First Name:KAREN
Middle Name:LUEBCKE
Last Name:WILTIN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10103 RIDGE GATE PARKWAY SUITE 125
Mailing Address - Street 2:
Mailing Address - City:LONE TREE
Mailing Address - State:CO
Mailing Address - Zip Code:80124
Mailing Address - Country:US
Mailing Address - Phone:303-790-8899
Mailing Address - Fax:303-790-2810
Practice Address - Street 1:10103 RIDGEGATE PKWY STE 125
Practice Address - Street 2:
Practice Address - City:LONE TREE
Practice Address - State:CO
Practice Address - Zip Code:80124-5525
Practice Address - Country:US
Practice Address - Phone:303-790-8899
Practice Address - Fax:303-790-2810
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2013-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2344363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
COCOA100408Medicare PIN
COCOA100410Medicare PIN