Provider Demographics
NPI:1740665744
Name:MCCOMB, IAN (PA-C)
Entity type:Individual
Prefix:
First Name:IAN
Middle Name:
Last Name:MCCOMB
Suffix:
Gender:M
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 1:777 BANNOCK ST # MC7782
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80204-4597
Mailing Address - Country:US
Mailing Address - Phone:303-436-6000
Mailing Address - Fax:
Practice Address - Street 1:777 BANNOCK ST # MC7782
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80204-4597
Practice Address - Country:US
Practice Address - Phone:303-436-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-21
Last Update Date:2024-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9108791363A00000X
COPA0005655363A00000X
COPA.0005655363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL015346200Medicaid
FLIG121ZMedicare PIN