Provider Demographics
NPI:1104883685
Name:BRUCE, TODD ROBERT (PA-C)
Entity type:Individual
Prefix:MR
First Name:TODD
Middle Name:ROBERT
Last Name:BRUCE
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 1:5331 W 1ST ST
Mailing Address - Street 2:
Mailing Address - City:GREELEY
Mailing Address - State:CO
Mailing Address - Zip Code:80634-4230
Mailing Address - Country:US
Mailing Address - Phone:970-352-5369
Mailing Address - Fax:
Practice Address - Street 1:1800 15TH ST
Practice Address - Street 2:SUITE 340
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80631-4500
Practice Address - Country:US
Practice Address - Phone:970-378-4593
Practice Address - Fax:970-378-4591
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2008-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2051363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO95650857Medicaid
COC801911Medicare PIN
COS09108Medicare UPIN