Individual
LUCAS R DERTING
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA-C
Contact information
Practice address
1600 NORTH GRAND AVENUE, SUITE 500, PUEBLO, CO 81003-2757
(719) 545-0663
(719) 595-7903
Mailing address
PO BOX 560825, DENVER, CO 80256-0825
(719) 595-7580
(719) 545-0176
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
1080
CO
363AS0400X
Surgical Physician Assistant
1080
CO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
63720345
—
CO
Enumeration date
07/29/2005
Last updated
11/03/2016
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