MEDICARE: ELFRIEDE E VERNON PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant
2	363AM0700X	Medical Physician Assistant	PA13986	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	PA13986	OTHER	CA	LICENSE

General Provider Information

NPI Number	:	1205003324
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELFRIEDE E VERNON PA

Provider Business Mailing Address
First Line	:	6351 WETZEL AVE BLDG 1525
Second Line	:
City	:	FORT CARSON
State	:	CO
Zip	:	80913-4188
Country	:	US
Telephone Number	:	719-524-4664
Fax Number	:	719-524-2116

Provider Business Practice Location Address
First Line	:	6351 WETZEL AVE BLDG 1525
Second Line	:
City	:	FORT CARSON
State	:	CO
Zip	:	80913-4188
Country	:	US
Telephone Number	:	719-524-4664
Fax Number	:	719-524-2116

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/08/2008
Last Update Date	:	05/13/2021

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Directions to “ ELFRIEDE E VERNON PA” Practice Location

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