NPIMap

Individual provider Active NPI

Lara M Antonelli, PA

  • Physician Assistant
  • Fort Collins, CO
National Provider Identifier
1275698904
Registry record updated Feb 28, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Physician AssistantTaxonomy code 363A00000X
License
PA 1669 Issued in CO
Practice address
1107 S Lemay Ave Ste 200
Fort Collins, CO 80524-3959
Phone
(970) 484-1757
Fax
(970) 484-9924
NPI assigned
Dec 22, 2006
Last updated
Feb 28, 2022By the provider in NPPES
Sex
Female
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Feb 28, 2022

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Physician Assistant 363A00000X PA 1669 CO Primary

Addresses

Primary practice location

1107 S Lemay Ave Ste 200
Fort Collins, CO 80524-3959

Mailing address

1107 S Lemay Ave Ste 200
Fort Collins, CO 80524-3959
Phone (970) 484-1757

Other identifiers 3

IdentifierTypeStateIssuer
55828876MedicaidCO
AN660037OtherCOBCBS
848020573009OtherCOROCKY MTN HMO

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in CO
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20080707000191 CO Practitioner - Physician Assistant 5294807343 Reassigns benefits to 4 organizations

Care Compare profile

Medicare Care Compare
Specialty
Physician Assistant
Education
Other, 2002
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Telehealth
Offers telehealth services
Group practices
Poudre Valley Medical Group LLCGroup PAC ID 9638208549, 2,425 clinicians

Practice addresses (Care Compare)

1100 E Prospect Rd
BLDG a
Fort Collins, CO 80525-5304
Phone (970) 297-6630

1106 E Prospect Rd
Building B Suite 100
Fort Collins, CO 80525-5304
Phone (970) 495-7410

4404 Barranca LN
Unit 101
Castle Rock, CO 80104-7419
Phone (720) 733-5260

Hospital & facility affiliations

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Physician Assistant

State licenses

LicenseStateTypeSpecialty
1669COMDClinical Psychologist
PA 1669COMDPhysician Assistant

Practice roles

OrganizationSpecialtyStatusNew patients
Emergency Physicians of the Rockies, PC CurrentSince Jul 10, 2017 Accepting new patients
Poudre Valley Medical Group, LLC CurrentSince Apr 14, 2025 Accepting new patients
Poudre Valley Medical Group, LLC CurrentSince Apr 14, 2025 Accepting new patients
Mountain Radiology, Inc Past Accepting new patients

Locations

1024 S Lemay Ave
Fort Collins, CO 80524
Phone (970) 495-7000

1100 E Prospect Rd
Bldg A
Fort Collins, CO 80525
Phone (970) 297-6630

1106 E Prospect Rd
Ste 100
Fort Collins, CO 80525
Phone (970) 224-3636

1107 S Lemay Ave
Ste 200
Fort Collins, CO 80524
Phone (970) 484-1757

3519 Richmond Dr
Fort Collins, CO 80526
Phone (970) 204-0300

Organizations & group practices 6

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

Hospital & facility affiliations 19

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

View all 19

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1166745600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1646006400000",
    "number": "1275698904",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1107 S LEMAY AVE STE 200",
            "city": "FORT COLLINS",
            "state": "CO",
            "postal_code": "805243959",
            "telephone_number": "970-484-1757",
            "fax_number": "970-484-9924"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1107 S LEMAY AVE STE 200",
            "city": "FORT COLLINS",
            "state": "CO",
            "postal_code": "805243959",
            "telephone_number": "970-484-1757",
            "fax_number": "970-484-9924"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "ANTONELLI",
        "first_name": "LARA",
        "middle_name": "M",
        "credential": "PA",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2006-12-22",
        "last_updated": "2022-02-28",
        "certification_date": "2022-02-28",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "CO",
            "license": "PA 1669",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "55828876",
            "state": "CO"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BCBS",
            "identifier": "AN660037",
            "state": "CO"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "ROCKY MTN HMO",
            "identifier": "848020573009",
            "state": "CO"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Fort Collins, CO

Sources for this page

Verify at the official NPI Registry.