MEDICARE: KARA LEAH DITULLIO PA C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	419KLD0514	OTHER	WY	SUBSTANCE CONTROL
2	345	OTHER	WY	STATE LICENSE

General Provider Information

NPI Number	:	1063495042
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KARA LEAH DITULLIO PA C

Provider Business Mailing Address
First Line	:	4674 SNOW MESA DR
Second Line	:	SUITE140
City	:	FORT COLLINS
State	:	CO
Zip	:	80528-8615
Country	:	US
Telephone Number	:	970-482-0213
Fax Number	:

Provider Business Practice Location Address
First Line	:	4674 SNOW MESA DR
Second Line	:	SUITE140
City	:	FORT COLLINS
State	:	CO
Zip	:	80528-8615
Country	:	US
Telephone Number	:	970-482-0213
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/23/2005
Last Update Date	:	10/16/2007

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Directions to “ KARA LEAH DITULLIO PA C” Practice Location

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