Basic Information
Provider Information | |||||||||
NPI: | 1376751024 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CAMPBELL | ||||||||
FirstName: | KAREN | ||||||||
MiddleName: | MARIE | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | MASSEY | ||||||||
OtherFirstName: | KAREN | ||||||||
OtherMiddleName: | MARIE | ||||||||
OtherNamePrefix: | MS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PA-C | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 501 AIRPORT RD | ||||||||
Address2: |   | ||||||||
City: | RIFLE | ||||||||
State: | CO | ||||||||
PostalCode: | 816508510 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9706251100 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 501 AIRPORT RD | ||||||||
Address2: |   | ||||||||
City: | RIFLE | ||||||||
State: | CO | ||||||||
PostalCode: | 816508510 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9706251100 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/18/2007 | ||||||||
LastUpdateDate: | 02/14/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 02/14/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 6019995-1206 | UT | N |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   | 363A00000X | 2566 | CO | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
ID Information
ID | Type | State | Issuer | Description | 1018636 | 01 |   | AAPA FELLOW ID | OTHER | 6019995-1206 | 01 | UT | PA STATE LICENSE NUMBER | OTHER | 12323701 | 01 |   | CAQH | OTHER | 6019995-8906 | 01 | UT | PA CS SCHEDULE 2-5 LICENS | OTHER | 2566 | 01 | CO | COLORADO STATE LICENSE | OTHER |