Basic Information
| Provider Information | |||||||||
| NPI: | 1609305630 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMALLWOOD | ||||||||
| FirstName: | HEATHER | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WOHLERS | ||||||||
| OtherFirstName: | HEATHER | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 9590 S ESTES WAY | ||||||||
| Address2: | |||||||||
| City: | LITTLETON | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801278512 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | |||||||||
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| Practice Location | |||||||||
| Address1: | 2801 PURCELL ST | ||||||||
| Address2: | |||||||||
| City: | BRIGHTON | ||||||||
| State: | CO | ||||||||
| PostalCode: | 806013551 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3036597600 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2017 | ||||||||
| LastUpdateDate: | 04/29/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 0004988 | CO | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 9000154959 | 05 | CO | MEDICAID |