Provider Demographics
NPI:1841365780
Name:EDMISTON, JULIE S (PA C)
Entity type:Individual
Prefix:
First Name:JULIE
Middle Name:S
Last Name:EDMISTON
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 1:2008 CARIBOU DR
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525-4325
Mailing Address - Country:US
Mailing Address - Phone:970-484-4757
Mailing Address - Fax:970-484-4759
Practice Address - Street 1:1024 S LEMAY AVE
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80524-3929
Practice Address - Country:US
Practice Address - Phone:970-495-7000
Practice Address - Fax:970-484-4759
Is Sole Proprietor?:No
Enumeration Date:2006-11-22
Last Update Date:2020-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LALA#A10389363A00000X
COPA.0006211363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1508489Medicaid
LA1508489Medicaid
LA1508489Medicaid