Provider Demographics
NPI:1205003324
Name:VERNON, ELFRIEDE E (PA)
Entity type:Individual
Prefix:
First Name:ELFRIEDE
Middle Name:E
Last Name:VERNON
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 1:6351 WETZEL AVE BLDG 1525
Mailing Address - Street 2:
Mailing Address - City:FORT CARSON
Mailing Address - State:CO
Mailing Address - Zip Code:80913-4188
Mailing Address - Country:US
Mailing Address - Phone:719-524-4664
Mailing Address - Fax:719-524-2116
Practice Address - Street 1:6351 WETZEL AVE BLDG 1525
Practice Address - Street 2:
Practice Address - City:FORT CARSON
Practice Address - State:CO
Practice Address - Zip Code:80913-4188
Practice Address - Country:US
Practice Address - Phone:719-524-4664
Practice Address - Fax:719-524-2116
Is Sole Proprietor?:No
Enumeration Date:2008-05-08
Last Update Date:2021-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
CAPA13986363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA13986OtherLICENSE