Basic Information
| Provider Information | |||||||||
| NPI: | 1760991459 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PAVLACKA | ||||||||
| FirstName: | AUBREY | ||||||||
| MiddleName: | DANELL | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 RUSH DR | ||||||||
| Address2: | |||||||||
| City: | SALIDA | ||||||||
| State: | CO | ||||||||
| PostalCode: | 812019627 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3169939833 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1000 RUSH DR | ||||||||
| Address2: | |||||||||
| City: | SALIDA | ||||||||
| State: | CO | ||||||||
| PostalCode: | 812019627 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195302200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/25/2017 | ||||||||
| LastUpdateDate: | 05/11/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 0005156 | CO | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.