Basic Information
| Provider Information | |||||||||
| NPI: | 1265449714 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FERGUSON | ||||||||
| FirstName: | CANDACE | ||||||||
| MiddleName: | ANNE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 129 KANSAS AVE | ||||||||
| Address2: | |||||||||
| City: | WALSENBURG | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810891818 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7197385200 | ||||||||
| FaxNumber: | 7197382732 | ||||||||
| Practice Location | |||||||||
| Address1: | 129 KANSAS AVE | ||||||||
| Address2: | |||||||||
| City: | WALSENBURG | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810891818 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7197385200 | ||||||||
| FaxNumber: | 7197382732 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2006 | ||||||||
| LastUpdateDate: | 07/29/2016 | ||||||||
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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 | 363LF0000X | APN.0000488-NP | CO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 07602501 | 05 | CO | MEDICAID |