Basic Information
| Provider Information | |||||||||
| NPI: | 1457612848 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BABCOCK | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | O'STEEN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | O'STEEN | ||||||||
| OtherFirstName: | AMANDA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 9049 | ||||||||
| Address2: | |||||||||
| City: | BOULDER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 803019049 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3034158940 | ||||||||
| FaxNumber: | 3034259259 | ||||||||
| Practice Location | |||||||||
| Address1: | 3 SUPERIOR DR STE 100B | ||||||||
| Address2: | |||||||||
| City: | SUPERIOR | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800278653 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3034158940 | ||||||||
| FaxNumber: | 3034259259 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2012 | ||||||||
| LastUpdateDate: | 09/29/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/29/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QS0010X | DR.0061542 | CO | N | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine | 207Q00000X | DR.0061542 | CO | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | A127022 | CA | N | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 9000170691 | 05 | CO | MEDICAID |