Provider Demographics
NPI:1265593834
Name:JEFFERS, DOUGLASS ALAN (PA-C)
Entity type:Individual
Prefix:
First Name:DOUGLASS
Middle Name:ALAN
Last Name:JEFFERS
Suffix:
Gender:M
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 1:4020 PALMER PARK BLVD STE 101B
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80909-3433
Mailing Address - Country:US
Mailing Address - Phone:719-577-9977
Mailing Address - Fax:719-577-9911
Practice Address - Street 1:4020 PALMER PARK BLVD STE 101B
Practice Address - Street 2:SUITE 109
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909-3433
Practice Address - Country:US
Practice Address - Phone:719-577-9977
Practice Address - Fax:719-577-9911
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO324363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO54358221Medicaid
CO324OtherSTATE LICENSE
CO811342OtherMEDICARE PPTAN
COMJ0429072OtherDEA #