Provider Demographics
NPI:1104148097
Name:PENROSE, PAMELA FAE (PA)
Entity type:Individual
Prefix:MS
First Name:PAMELA
Middle Name:FAE
Last Name:PENROSE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MRS
Other - First Name:BARBARA
Other - Middle Name:
Other - Last Name:HOSICK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MGR
Mailing Address - Street 1:1021 DEXTER ST
Mailing Address - Street 2:
Mailing Address - City:BROOMFIELD
Mailing Address - State:CO
Mailing Address - Zip Code:80020-1458
Mailing Address - Country:US
Mailing Address - Phone:303-996-6005
Mailing Address - Fax:
Practice Address - Street 1:3555 LUTHERAN PKWY
Practice Address - Street 2:STE 340
Practice Address - City:WHEAT RIDGE
Practice Address - State:CO
Practice Address - Zip Code:80033-6021
Practice Address - Country:US
Practice Address - Phone:303-005-9966
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-19
Last Update Date:2010-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO303363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant