Provider Demographics
NPI:1386989135
Name:PFEIFER, JODY BREANN
Entity type:Individual
Prefix:
First Name:JODY
Middle Name:BREANN
Last Name:PFEIFER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JODY
Other - Middle Name:B
Other - Last Name:PFEIFER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 173862
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80217-3862
Mailing Address - Country:US
Mailing Address - Phone:303-306-7783
Mailing Address - Fax:303-306-7753
Practice Address - Street 1:1501 S POTOMAC ST
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80012-5411
Practice Address - Country:US
Practice Address - Phone:303-695-2628
Practice Address - Fax:303-306-7753
Is Sole Proprietor?:No
Enumeration Date:2012-12-05
Last Update Date:2015-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1107457363A00000X
COPA.0004228363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO16087771Medicaid
CO16087771Medicaid