Healthcare Provider Details

I. General information

NPI: 1275204802
Provider Name (Legal Business Name): DOMINICA ANNABETH HADLEY PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2021
Last Update Date: 02/27/2026
Certification Date: 02/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2101 KEN PRATT BLVD STE 104A
LONGMONT CO
80501-6568
US

IV. Provider business mailing address

PO BOX 9049
BOULDER CO
80301-9049
US

V. Phone/Fax

Practice location:
  • Phone: 303-415-4155
  • Fax: 303-776-3109
Mailing address:
  • Phone: 303-415-4101
  • Fax: 303-415-4769

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA.0009638
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number14612
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: