MEDICARE: ANDREW RICHARD DOMER 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	363AS0400X	Surgical Physician Assistant	4155	CO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	11561458	OTHER		CAQH NUMBER

General Provider Information

NPI Number	:	1841231230
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANDREW RICHARD DOMER PA-C

Provider Business Mailing Address
First Line	:	8101 E LOWRY BLVD
Second Line	:	STE 120
City	:	DENVER
State	:	CO
Zip	:	80230-7195
Country	:	US
Telephone Number	:	303-806-1998
Fax Number	:

Provider Business Practice Location Address
First Line	:	3920 N UNION BLVD STE 330
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80907-4916
Country	:	US
Telephone Number	:	719-570-7272
Fax Number	:	719-570-9030

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

Provider Enumeration Date	:	06/09/2006
Last Update Date	:	06/11/2021

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