Healthcare Provider Details

I. General information

NPI: 1083675995
Provider Name (Legal Business Name): ANDREA L GRACE P.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ANDREA L BACA PA

II. Dates (important events)

Enumeration Date: 03/30/2006
Last Update Date: 11/14/2023
Certification Date: 11/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1721 E 19TH AVE STE 300
DENVER CO
80218-1258
US

IV. Provider business mailing address

4900 S. MONACO ST #210
DENVER CO
80237-3486
US

V. Phone/Fax

Practice location:
  • Phone: 720-754-4800
  • Fax: 720-754-4801
Mailing address:
  • Phone: 720-754-4800
  • Fax: 720-754-4801

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number2260
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: