Provider Demographics
NPI:1023342961
Name:HERRAEZ SANCHEZ, JUAN CARLOS (PA-C)
Entity type:Individual
Prefix:MR
First Name:JUAN
Middle Name:CARLOS
Last Name:HERRAEZ SANCHEZ
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:MR
Other - First Name:JUAN
Other - Middle Name:CARLOS
Other - Last Name:HERRAEZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:1600 W 24TH ST
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81003-1411
Mailing Address - Country:US
Mailing Address - Phone:719-546-4402
Mailing Address - Fax:
Practice Address - Street 1:1600 W 24TH ST
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81003-1411
Practice Address - Country:US
Practice Address - Phone:719-546-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-24
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2876363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
COMH2038378OtherDEA