Provider Demographics
NPI:1558335778
Name:VERRECCHIA, DOMINIQUE A (PA)
Entity type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:A
Last Name:VERRECCHIA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:777 BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80204-4597
Mailing Address - Country:US
Mailing Address - Phone:303-436-4200
Mailing Address - Fax:303-436-4448
Practice Address - Street 1:777 BANNOCK ST
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80204-4507
Practice Address - Country:US
Practice Address - Phone:303-436-4200
Practice Address - Fax:303-436-4448
Is Sole Proprietor?:No
Enumeration Date:2006-02-14
Last Update Date:2024-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1318363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO06403743Medicaid
CO807257Medicare PIN
CO06403743Medicaid