Basic Information
| Provider Information | |||||||||
| NPI: | 1184685323 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOATNER | ||||||||
| FirstName: | MARGO | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PAC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | COLLETTE | ||||||||
| OtherFirstName: | MARGO | ||||||||
| OtherMiddleName: | C. | ||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PAC | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 940 CENTRAL PARK DR | ||||||||
| Address2: | STE 280 | ||||||||
| City: | STEAMBOAT SPGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 80487 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9708796663 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 940 CENTRAL PARK DR | ||||||||
| Address2: | STE 280 | ||||||||
| City: | STEAMBOAT SPGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 80487 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9708796663 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2006 | ||||||||
| LastUpdateDate: | 04/23/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 72436069 | 05 | CO | MEDICAID | 2180 | 01 | COLORADO STATE LICENSE | OTHER | MC1343879 | 01 | DEA COLORADO | OTHER |