Basic Information
| Provider Information | |||||||||
| NPI: | 1649278318 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VASQUEZ | ||||||||
| FirstName: | JOSE | ||||||||
| MiddleName: | LUIS | ||||||||
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| Credential: | FNP-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 928 12TH STREET | ||||||||
| Address2: | |||||||||
| City: | GREELEY | ||||||||
| State: | CO | ||||||||
| PostalCode: | 806314024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9703521056 | ||||||||
| FaxNumber: | 9703365000 | ||||||||
| Practice Location | |||||||||
| Address1: | 7871 S. QUEBEC STREET | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | HIGHLANDS RANCH | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801305861 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3036835620 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2005 | ||||||||
| LastUpdateDate: | 02/04/2016 | ||||||||
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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 | 363LP0808X | APN0002658 | CO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 363LP0808X | 109020 | CO | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 91002761 | 05 | CO | MEDICAID |