Provider Demographics
NPI:1043490121
Name:MATTIE, CORA NICOLE (PA-C)
Entity type:Individual
Prefix:
First Name:CORA
Middle Name:NICOLE
Last Name:MATTIE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4045 PECOS ST STE 150
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80211-2561
Mailing Address - Country:US
Mailing Address - Phone:720-730-7664
Mailing Address - Fax:720-815-3104
Practice Address - Street 1:4045 PECOS ST STE 150
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80211-2561
Practice Address - Country:US
Practice Address - Phone:720-730-7664
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-06
Last Update Date:2025-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA001867363A00000X
CO0003181363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant