Provider Demographics
NPI:1083675995
Name:GRACE, ANDREA L (PA)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:L
Last Name:GRACE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:ANDREA
Other - Middle Name:L
Other - Last Name:BACA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:4900 S. MONACO ST
Mailing Address - Street 2:#210
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80237-3486
Mailing Address - Country:US
Mailing Address - Phone:720-754-4800
Mailing Address - Fax:720-754-4801
Practice Address - Street 1:1721 E 19TH AVE STE 300
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80218-1258
Practice Address - Country:US
Practice Address - Phone:720-754-4800
Practice Address - Fax:720-754-4801
Is Sole Proprietor?:No
Enumeration Date:2006-03-30
Last Update Date:2023-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2260363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO85289221Medicaid
COCOAAA1569OtherMEDICARE
ILQ61399Medicare UPIN
CO85289221Medicaid
COCOAAA1569OtherMEDICARE