Healthcare Provider Details

I. General information

NPI: 1447339536
Provider Name (Legal Business Name): DOUGLAS PENN HORNBERGER P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2006
Last Update Date: 11/17/2020
Certification Date: 11/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2695 ROCKY MOUNTAIN AVE STE 110
LOVELAND CO
80538-9074
US

IV. Provider business mailing address

2695 ROCKY MOUNTAIN AVE STE 110
LOVELAND CO
80538-9074
US

V. Phone/Fax

Practice location:
  • Phone: 970-482-4373
  • Fax:
Mailing address:
  • Phone: 970-482-4373
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA.0002158
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number2158
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: