Provider Demographics
NPI:1386983542
Name:KASPERBAUER, REBECCA ANN (PA-C)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:ANN
Last Name:KASPERBAUER
Suffix:
Gender:F
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 1:17 VASSAR CT
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80503-2134
Mailing Address - Country:US
Mailing Address - Phone:720-971-2649
Mailing Address - Fax:
Practice Address - Street 1:2575 SPRUCE ST
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80302-3806
Practice Address - Country:US
Practice Address - Phone:303-449-3594
Practice Address - Fax:303-449-3112
Is Sole Proprietor?:No
Enumeration Date:2013-02-07
Last Update Date:2018-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA.0003511363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant