Basic Information
| Provider Information | |||||||||
| NPI: | 1639655079 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KLUTZ | ||||||||
| FirstName: | STEPHANIE | ||||||||
| MiddleName: | JO | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BROLSMA | ||||||||
| OtherFirstName: | STEPHANIE | ||||||||
| OtherMiddleName: | JO | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PA-C | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2535 S DOWNING ST STE 180F | ||||||||
| Address2: | |||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802105847 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3037620808 | ||||||||
| FaxNumber: | 3037629292 | ||||||||
| Practice Location | |||||||||
| Address1: | 2535 S DOWNING ST STE 180F | ||||||||
| Address2: | |||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802105847 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3037620808 | ||||||||
| FaxNumber: | 3037629292 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2018 | ||||||||
| LastUpdateDate: | 04/03/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA.0005428 | CO | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | PA.0005428 | 01 | CO | COLORADO DEPARTMENT OF REGULATORY AGENCIES | OTHER | 1152106 | 01 | NCCPA | OTHER |