Provider Demographics
NPI:1841862422
Name:VALLEJO, CHRISTOPHER MICHAEL (PA-C)
Entity type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:MICHAEL
Last Name:VALLEJO
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 1:1455 DIXON AVE
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:CO
Mailing Address - Zip Code:80026-8879
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1455 DIXON AVE
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:CO
Practice Address - Zip Code:80026-8879
Practice Address - Country:US
Practice Address - Phone:303-519-3268
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-14
Last Update Date:2023-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA.0006884363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000196429Medicaid