Healthcare Provider Details

I. General information

NPI: 1780238436
Provider Name (Legal Business Name): MICHAEL VAN PELT PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2019
Last Update Date: 04/09/2026
Certification Date: 04/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6810 10TH ST
GREELEY CO
80634-8254
US

IV. Provider business mailing address

6810 10TH ST
GREELEY CO
80634-8254
US

V. Phone/Fax

Practice location:
  • Phone: 970-710-3033
  • Fax:
Mailing address:
  • Phone: 970-710-3033
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA.0007067
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA18266
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number13128
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: