Healthcare Provider Details

I. General information

NPI: 1417520024
Provider Name (Legal Business Name): MATTHEW FOCAZIO PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2021
Last Update Date: 07/21/2021
Certification Date: 07/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1325 S COLORADO BLVD STE 509
DENVER CO
80222-3320
US

IV. Provider business mailing address

3329 E BAYAUD AVE APT 509
DENVER CO
80209-3342
US

V. Phone/Fax

Practice location:
  • Phone: 303-321-0123
  • Fax:
Mailing address:
  • Phone: 386-290-7028
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA.0006767
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: