Basic Information
| Provider Information | |||||||||
| NPI: | 1124135264 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NOTEBOOM | ||||||||
| FirstName: | KURT | ||||||||
| MiddleName: | DOUGLAS | ||||||||
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| Credential: | PA-C, ATC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8426 ZINNIA CT | ||||||||
| Address2: | |||||||||
| City: | ARVADA | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800051100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3039529926 | ||||||||
| FaxNumber: | 3034363054 | ||||||||
| Practice Location | |||||||||
| Address1: | 80 HEALTH PARK DR | ||||||||
| Address2: | #230 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800279584 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3036652603 | ||||||||
| FaxNumber: | 3036652605 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/24/2006 | ||||||||
| LastUpdateDate: | 01/15/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 10057 | MN | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 738 | CO | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 322152100 | 05 | MN | MEDICAID |