Provider Demographics
NPI:1447339536
Name:HORNBERGER, DOUGLAS PENN (PA)
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:PENN
Last Name:HORNBERGER
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2695 ROCKY MOUNTAIN AVE STE 110
Mailing Address - Street 2:
Mailing Address - City:LOVELAND
Mailing Address - State:CO
Mailing Address - Zip Code:80538-9074
Mailing Address - Country:US
Mailing Address - Phone:970-482-4373
Mailing Address - Fax:
Practice Address - Street 1:2695 ROCKY MOUNTAIN AVE STE 110
Practice Address - Street 2:
Practice Address - City:LOVELAND
Practice Address - State:CO
Practice Address - Zip Code:80538-9074
Practice Address - Country:US
Practice Address - Phone:970-482-4373
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2158363AM0700X
COPA.0002158363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO65356276Medicaid
CO65356276Medicaid