Basic Information
| Provider Information | |||||||||
| NPI: | 1104841337 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WESTERN STATES PATHOLOGY, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | NORTHERN COLORADO CYTOLOGY SERVICE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 2918 W 10TH ST | ||||||||
| Address2: | |||||||||
| City: | GREELEY | ||||||||
| State: | CO | ||||||||
| PostalCode: | 806345476 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9703535136 | ||||||||
| FaxNumber: | 9703535614 | ||||||||
| Practice Location | |||||||||
| Address1: | 2918 W 10TH ST | ||||||||
| Address2: | |||||||||
| City: | GREELEY | ||||||||
| State: | CO | ||||||||
| PostalCode: | 806345476 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9703535136 | ||||||||
| FaxNumber: | 9703535614 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2006 | ||||||||
| LastUpdateDate: | 12/20/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LAMBERT | ||||||||
| AuthorizedOfficialFirstName: | JILL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9703535136 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | CO | Y | Laboratories | Clinical Medical Laboratory |
ID Information
| ID | Type | State | Issuer | Description | 536328 | 01 | CO | BLUE CROSS BLUE SHIELD | OTHER | 06278566 | 05 | CO | MEDICAID | 536328 | 01 | CO | ROCKY MOUNTAIN HEALTH PLA | OTHER |