Provider Demographics
NPI:1306973367
Name:NEUSTEDTER, PAUL L (PA)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:L
Last Name:NEUSTEDTER
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1551 MILKY WAY
Mailing Address - Street 2:
Mailing Address - City:THORTON
Mailing Address - State:CO
Mailing Address - Zip Code:80260-2444
Mailing Address - Country:US
Mailing Address - Phone:303-426-4525
Mailing Address - Fax:
Practice Address - Street 1:1375 E 19TH AVE
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80218-1114
Practice Address - Country:US
Practice Address - Phone:303-338-4545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2021-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO817207P00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO71783377Medicaid
009266OtherKAISER-COMMERCIAL NUMBER
CO71783377Medicaid
COS16485Medicare UPIN