Basic Information
Provider Information | |||||||||
NPI: | 1740467497 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | COLE | ||||||||
FirstName: | KATIE | ||||||||
MiddleName: | A | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 9224 TEDDY LN | ||||||||
Address2: | SUITE 200 | ||||||||
City: | LONETREE | ||||||||
State: | CO | ||||||||
PostalCode: | 801246798 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3037901515 | ||||||||
FaxNumber: | 3037901989 | ||||||||
Practice Location | |||||||||
Address1: | 9224 TEDDY LN | ||||||||
Address2: | SUITE 220 | ||||||||
City: | LONETREE | ||||||||
State: | CO | ||||||||
PostalCode: | 801246798 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3037901515 | ||||||||
FaxNumber: | 3037901989 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/24/2008 | ||||||||
LastUpdateDate: | 11/28/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 2556 | CO | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
ID Information
ID | Type | State | Issuer | Description | 04018362 | 01 | CO | GROUP MEDICAID | OTHER | 1699895755 | 01 |   | GROUP NPI | OTHER | 109864100 | 01 | WY | GROUP MEDICAID | OTHER | 200293420 A | 01 | OK | GROUP MEDICAID | OTHER | 56529767 | 05 | CO |   | MEDICAID | 84127410413 | 01 | NE | GROUP MEDICAID | OTHER |