Organization
PEDIATRIC ASSOCIATES OF CANON CITY, PROF. LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. ROGER DEANE NOLAND (GENERAL MANAGER)
(719) 269-1727
Entity
Organization
Contact information
Practice address
1335 PHAY AVE, SUITE A, CANON CITY, CO 81212-2334
(719) 269-1727
(719) 269-1730
Mailing address
1335 PHAY AVE, SUITE A, CANON CITY, CO 81212-2334
(719) 269-1727
(719) 269-1730
Taxonomy
Speciality
Code
Description
License number
State
2080A0000X
Pediatric Adolescent Medicine Physician
Primary
23117
CO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
01271139
—
CO
05
—
05638655
—
CO
Enumeration date
01/31/2007
Last updated
08/22/2020
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