MEDICARE: MRS. DEBORAH E LIEBERMAN PA-C

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	363AM0700X	Medical Physician Assistant	PA.0004499	CO
2	363AS0400X	Surgical Physician Assistant	PA.0004499	CO
3	363A00000X	Physician Assistant	PA.0004499	CO

General Provider Information

NPI Number	:	1639533540
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. DEBORAH E LIEBERMAN PA-C

Provider Business Mailing Address
First Line	:	416 SCOTT AVE
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80521-2465
Country	:	US
Telephone Number	:	303-947-9457
Fax Number	:

Provider Business Practice Location Address
First Line	:	2900 S COLLEGE AVE STE 3G
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80525-2562
Country	:	US
Telephone Number	:	970-300-3323
Fax Number	:

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

Provider Enumeration Date	:	04/06/2016
Last Update Date	:	12/07/2020

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