Provider Demographics
NPI:1033180518
Name:DEITZ, MICHEAL (PA-C)
Entity type:Individual
Prefix:MR
First Name:MICHEAL
Middle Name:
Last Name:DEITZ
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 1:2315 E HARMONY RD STE 170
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80528-8620
Mailing Address - Country:US
Mailing Address - Phone:970-495-8450
Mailing Address - Fax:970-297-6599
Practice Address - Street 1:2315 E HARMONY RD STE 170
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80528-8620
Practice Address - Country:US
Practice Address - Phone:970-495-8450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-31
Last Update Date:2020-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO560363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
COP00944690OtherMEDICARE RAILROAD CARRIER PTAN
CO07005606Medicaid
COCOA104036Medicare PIN
COS06379Medicare UPIN
COCO306727Medicare PIN
CO07005606Medicaid