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NPI Code Detail

MEDICARE: LARA M ANTONELLI PA

MEDICARE: LARA M ANTONELLI PA
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
1363A00000XPhysician AssistantPA 1669CO

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1848020573009OTHERCOROCKY MTN HMO
2AN660037OTHERCOBCBS
3MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1275698904
Entity Type Code : Individual
Provider Name (Legal Business Name) : LARA M ANTONELLI PA
Provider Business Mailing Address
First Line : 1107 S LEMAY AVE STE 200
Second Line :
City : FORT COLLINS
State : CO
Zip : 80524-3959
Country : US
Telephone Number : 970-484-1757
Fax Number : 970-484-9924
Provider Business Practice Location Address
First Line : 1107 S LEMAY AVE STE 200
Second Line :
City : FORT COLLINS
State : CO
Zip : 80524-3959
Country : US
Telephone Number : 970-484-1757
Fax Number : 970-484-9924
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 12/22/2006
Last Update Date : 02/28/2022

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Directions to “ LARA M ANTONELLI PA” Practice Location

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