Provider Demographics
NPI:1962532705
Name:PELIKAN, SUSAN M (PA)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:M
Last Name:PELIKAN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:M
Other - Last Name:FOUTS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8383 W ALAMEDA AVE
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80226-3007
Mailing Address - Country:US
Mailing Address - Phone:303-338-4545
Mailing Address - Fax:
Practice Address - Street 1:8383 W ALAMEDA AVE
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80226-3007
Practice Address - Country:US
Practice Address - Phone:303-338-4545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2014-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
CO2126363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO24752762Medicaid
017033OtherKAISER-COMMERCIAL NUMBER
CO24752762Medicaid
COCO307434Medicare PIN