Provider Demographics
NPI:1154548824
Name:RIEKS, JEREMY A (PA-C)
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:A
Last Name:RIEKS
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 1:3425 S. CLARKSON
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80113-2811
Mailing Address - Country:US
Mailing Address - Phone:303-789-8220
Mailing Address - Fax:303-789-8470
Practice Address - Street 1:3425 S. CLARKSON
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80113-2811
Practice Address - Country:US
Practice Address - Phone:303-789-8220
Practice Address - Fax:303-789-8470
Is Sole Proprietor?:No
Enumeration Date:2007-04-20
Last Update Date:2012-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1719363AM0700X
COPA-1719363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1891908042OtherGROUP NPI
CO15204OtherMEDICARE GROUP
COQ52408Medicare UPIN