Basic Information
| Provider Information | |||||||||
| NPI: | 1518940899 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SCHACK | ||||||||
| FirstName: | ANGIE | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9777 S YOSEMITE ST | ||||||||
| Address2: | STE. 220 | ||||||||
| City: | LONETREE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801243191 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3036997325 | ||||||||
| FaxNumber: | 3036995486 | ||||||||
| Practice Location | |||||||||
| Address1: | 9777 S YOSEMITE ST | ||||||||
| Address2: | STE. 220 | ||||||||
| City: | LONETREE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801243191 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3036997325 | ||||||||
| FaxNumber: | 3036995486 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/21/2005 | ||||||||
| LastUpdateDate: | 12/28/2011 | ||||||||
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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 | 1756 | CO | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 81188544 | 05 | CO | MEDICAID |