Provider Demographics
NPI:1134202617
Name:BONTRAGER, REBECCA JEAN (PA)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:JEAN
Last Name:BONTRAGER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:JEAN
Other - Last Name:DANIELEWICZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1411 S POTOMAC ST
Mailing Address - Street 2:SUITE 400
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80012-4536
Mailing Address - Country:US
Mailing Address - Phone:303-695-6060
Mailing Address - Fax:303-369-7776
Practice Address - Street 1:1411 S POTOMAC ST
Practice Address - Street 2:SUITE 400
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80012-4536
Practice Address - Country:US
Practice Address - Phone:303-695-6060
Practice Address - Fax:303-369-7776
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2014-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2580363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO11576766Medicaid
CO11576766Medicaid
NE1245556091Medicaid
CO11576766Medicaid
CO265025YMCJMedicare PIN
COP01141080Medicare PIN
CO1134202617Medicaid
KS200975360AMedicaid