Basic Information
Provider Information | |||||||||
NPI: | 1477570455 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CALLAHAN | ||||||||
FirstName: | CAROL | ||||||||
MiddleName: | L | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | NP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 750 W HAMPDEN AVE | ||||||||
Address2: | SUITE 105 | ||||||||
City: | ENGLEWOOD | ||||||||
State: | CO | ||||||||
PostalCode: | 801102165 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3033414730 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 13650 E MISSISSIPPI AVE | ||||||||
Address2: | SUITE 100B | ||||||||
City: | AURORA | ||||||||
State: | CO | ||||||||
PostalCode: | 800123561 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3033414730 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/16/2006 | ||||||||
LastUpdateDate: | 11/30/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 4174 | CO | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
ID | Type | State | Issuer | Description | 91082056 | 05 | CO |   | MEDICAID | C-APN4174 | 01 | CO | STATE NP LICENSE | OTHER |