Provider Demographics
NPI:1669401261
Name:PACK, BETH (PA)
Entity type:Individual
Prefix:
First Name:BETH
Middle Name:
Last Name:PACK
Suffix:
Gender:F
Credentials:PA
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 429
Mailing Address - Street 2:
Mailing Address - City:SALIDA
Mailing Address - State:CO
Mailing Address - Zip Code:81201-0429
Mailing Address - Country:US
Mailing Address - Phone:719-530-2000
Mailing Address - Fax:
Practice Address - Street 1:550 W HWY 50
Practice Address - Street 2:
Practice Address - City:SALIDA
Practice Address - State:CO
Practice Address - Zip Code:81201-2238
Practice Address - Country:US
Practice Address - Phone:719-539-2048
Practice Address - Fax:719-539-2055
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2021-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2953363A00000X
COPA-2578363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ78316Medicare ID - Type Unspecified
COQ08058Medicare UPIN
COCK1808Medicare PIN