MEDICARE: DOMINIQUE IGOE 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	363AM0700X	Medical Physician Assistant	3369	CO

General Provider Information

NPI Number	:	1184990731
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DOMINIQUE IGOE PA-C

Provider Business Mailing Address
First Line	:	PO BOX 40065
Second Line	:
City	:	DENVER
State	:	CO
Zip	:	80204-0065
Country	:	US
Telephone Number	:	720-580-8001
Fax Number	:	720-580-8001

Provider Business Practice Location Address
First Line	:	2802 MADISON SQUARE DR
Second Line	:	100
City	:	LOVELAND
State	:	CO
Zip	:	80538-3396
Country	:	US
Telephone Number	:	970-221-9451
Fax Number	:	970-416-9676

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

Provider Enumeration Date	:	03/28/2012
Last Update Date	:	08/05/2016

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