Provider Demographics
NPI:1295492064
Name:SODERBERG, AVERY LEIGH (PA-C)
Entity type:Individual
Prefix:
First Name:AVERY
Middle Name:LEIGH
Last Name:SODERBERG
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:AVERY
Other - Middle Name:LEIGH
Other - Last Name:BELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6233 HARVARD LN
Mailing Address - Street 2:
Mailing Address - City:HIGHLANDS RANCH
Mailing Address - State:CO
Mailing Address - Zip Code:80130-3773
Mailing Address - Country:US
Mailing Address - Phone:720-217-5694
Mailing Address - Fax:
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:2021-11-29
Last Update Date:2022-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA.0007113363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical