Provider Demographics
NPI:1356538177
Name:STANTON, SUSAN GRACE (PA-C)
Entity type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:GRACE
Last Name:STANTON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:
Other - Last Name:GRACE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2500 ROCKY MOUNTAIN AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LOVELAND
Mailing Address - State:CO
Mailing Address - Zip Code:80538-9004
Mailing Address - Country:US
Mailing Address - Phone:970-624-1800
Mailing Address - Fax:970-624-1891
Practice Address - Street 1:2500 ROCKY MOUNTAIN AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:LOVELAND
Practice Address - State:CO
Practice Address - Zip Code:80538-9004
Practice Address - Country:US
Practice Address - Phone:970-624-1800
Practice Address - Fax:970-624-1891
Is Sole Proprietor?:No
Enumeration Date:2007-09-25
Last Update Date:2017-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA.0002498363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY134090500Medicaid
COP00757962OtherRR MEDICARE
CO69054371Medicaid
COCO304142Medicare PIN