Healthcare Provider Details

I. General information

NPI: 1639533540
Provider Name (Legal Business Name): DEBORAH E LIEBERMAN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2016
Last Update Date: 12/07/2020
Certification Date: 11/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 S COLLEGE AVE STE 3G
FORT COLLINS CO
80525-2562
US

IV. Provider business mailing address

416 SCOTT AVE
FORT COLLINS CO
80521-2465
US

V. Phone/Fax

Practice location:
  • Phone: 970-300-3323
  • Fax:
Mailing address:
  • Phone: 303-947-9457
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA.0004499
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA.0004499
License Number StateCO
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA.0004499
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: