Basic Information
| Provider Information | |||||||||
| NPI: | 1356538177 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STANTON | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | GRACE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | P.A.-C. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GRACE | ||||||||
| OtherFirstName: | SUSAN | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2500 ROCKY MOUNTAIN AVE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | LOVELAND | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805389004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9706241800 | ||||||||
| FaxNumber: | 9706241891 | ||||||||
| Practice Location | |||||||||
| Address1: | 2500 ROCKY MOUNTAIN AVE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | LOVELAND | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805389004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9706241800 | ||||||||
| FaxNumber: | 9706241891 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/25/2007 | ||||||||
| LastUpdateDate: | 01/09/2017 | ||||||||
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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 | PA.0002498 | CO | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 134090500 | 05 | WY | MEDICAID | P00757962 | 01 | CO | RR MEDICARE | OTHER | 69054371 | 05 | CO | MEDICAID |