Basic Information
| Provider Information | |||||||||
| NPI: | 1689983884 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KROTO | ||||||||
| FirstName: | BRYN | ||||||||
| MiddleName: | LAUREN | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8540 SCARBOROUGH DR | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809207502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7199554200 | ||||||||
| FaxNumber: | 7193657667 | ||||||||
| Practice Location | |||||||||
| Address1: | 320 E FONTANERO ST STE 100 | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809077535 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7199554200 | ||||||||
| FaxNumber: | 7193657667 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2010 | ||||||||
| LastUpdateDate: | 10/16/2018 | ||||||||
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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 | PA.0003096 | CO | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 60907835 | 05 | CO | MEDICAID |