Basic Information
| Provider Information | |||||||||
| NPI: | 1477645448 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | STOETZER | ||||||||
| FirstName: | KEITH | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4700 HALE PKWY | ||||||||
| Address2: | SUITE 550 | ||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802204045 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3033216600 | ||||||||
| FaxNumber: | 3033218814 | ||||||||
| Practice Location | |||||||||
| Address1: | 4700 HALE PKWY | ||||||||
| Address2: | SUITE 550 | ||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802204045 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3033216600 | ||||||||
| FaxNumber: | 3033218814 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2006 | ||||||||
| LastUpdateDate: | 11/25/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA0637 | CO | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 07063704 | 05 | CO | MEDICAID |