Basic Information
| Provider Information | |||||||||
| NPI: | 1306010970 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VIROSTKO | ||||||||
| FirstName: | AMELIA | ||||||||
| MiddleName: | ELISSA | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 203 S ROLLIE AVE | ||||||||
| Address2: | |||||||||
| City: | FORT LUPTON | ||||||||
| State: | CO | ||||||||
| PostalCode: | 806211508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3032864560 | ||||||||
| FaxNumber: | 3032864589 | ||||||||
| Practice Location | |||||||||
| Address1: | 1635 BLUE SPRUCE DR | ||||||||
| Address2: | |||||||||
| City: | FORT COLLINS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805245427 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9704944040 | ||||||||
| FaxNumber: | 9704944076 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/15/2008 | ||||||||
| LastUpdateDate: | 05/19/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | DR.0049964 | CO | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00579076 | 05 | CO | MEDICAID |