Basic Information
| Provider Information | |||||||||
| NPI: | 1174660534 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BABCOCK | ||||||||
| FirstName: | TERRA | ||||||||
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| Credential: | P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 151 W LAKE ST STE 1500 | ||||||||
| Address2: | |||||||||
| City: | FORT COLLINS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805244124 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9702378200 | ||||||||
| FaxNumber: | 9702378291 | ||||||||
| Practice Location | |||||||||
| Address1: | 151 W LAKE ST STE 1500 | ||||||||
| Address2: | |||||||||
| City: | FORT COLLINS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 80524 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9702378200 | ||||||||
| FaxNumber: | 9702378291 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/01/2007 | ||||||||
| LastUpdateDate: | 10/29/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 1337 | CO | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 90478339 | 05 | CO | MEDICAID |