Lucas R Derting, PA-C

Primary specialty

Physician AssistantTaxonomy code 363A00000X

License

1080 Issued in CO

Practice address

1600 North Grand Avenue
Suite 500
Pueblo, CO 81003-2757

Phone

(719) 545-0663

Fax

(719) 595-7903

NPI assigned

Jul 29, 2005

Reactivated

Apr 11, 2006

Sex

Male

Sole proprietor

No

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

Specialties & licenses 2

Addresses

Other identifiers 1

Medicare fee-for-service enrollment

Enrolled in CO

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: No

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

Credentials

Physician Assistant

State licenses

Practice roles

Locations

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.

• Pueblo Pathology Group, PC

  • Anatomic Pathology & Clinical Pathology Physician
  • Pueblo, CO
  • NPI 1275690588
  NPD
• Dexter D Koons MD PC

  • Specialist
  • Pueblo, CO
  • NPI 1336102086
  NPD (past)
• Poudre Valley Medical Group, LLC

  dba UCHealth Medical Group

  • General Practice Physician
  • Loveland, CO
  • NPI 1225356868
  NPD (past)

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

{
    "created_epoch": "1122595200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1478131200000",
    "number": "1306846381",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 560825",
            "city": "DENVER",
            "state": "CO",
            "postal_code": "802560825",
            "telephone_number": "719-595-7580",
            "fax_number": "719-545-0176"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1600 NORTH GRAND AVENUE",
            "address_2": "SUITE 500",
            "city": "PUEBLO",
            "state": "CO",
            "postal_code": "810032757",
            "telephone_number": "719-545-0663",
            "fax_number": "719-595-7903"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "DERTING",
        "first_name": "LUCAS",
        "middle_name": "R",
        "credential": "PA-C",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2005-07-29",
        "last_updated": "2016-11-03",
        "deactivation_date": "2006-03-22",
        "reactivation_date": "2006-04-11",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "CO",
            "license": "1080",
            "primary": true
        },
        {
            "code": "363AS0400X",
            "taxonomy_group": "",
            "desc": "Physician Assistant, Surgical",
            "state": "CO",
            "license": "1080",
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "63720345",
            "state": "CO"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Kenneth D Dernovsek, MD
• Kim K Dernovsek, MD
• Derose Children's Dental Clinic, PC
• Michael Anthony Derose
• Katherine R Derossett, NP
• Scott Alan Deruiter, M.D.
• Roberta Martha Desalvo, LPCC
• Desert Bloom Mental Health LLC
• Desert Willow Health and Rehabilitation Center LLC
• Desert Willow Health and Rehabilitation Center LLC (Desert Willow Health and Rehabilitation Center)

• Physician Assistant in Pueblo, CO
• Providers in Pueblo, CO by specialty
• Physician Assistant in Colorado

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 3, 2016; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.