Provider Demographics
NPI:1902162084
Name:KROEPSCH, LARA M (PA)
Entity Type:Individual
Prefix:
First Name:LARA
Middle Name:M
Last Name:KROEPSCH
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 1:345 MAXWELL AVE
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80304-3972
Mailing Address - Country:US
Mailing Address - Phone:303-544-5783
Mailing Address - Fax:303-441-2388
Practice Address - Street 1:311 MAPLETON AVE
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80304-3979
Practice Address - Country:US
Practice Address - Phone:303-544-5700
Practice Address - Fax:303-544-5710
Is Sole Proprietor?:No
Enumeration Date:2012-04-03
Last Update Date:2012-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA-3412363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1103169OtherNCCPA
CO12139858Medicaid
CO12139858Medicaid