Basic Information
| Provider Information | |||||||||
| NPI: | 1760647002 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HOUTZ | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | B | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4900 S MONACO ST | ||||||||
| Address2: | SUITE 210 | ||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802373486 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3038612263 | ||||||||
| FaxNumber: | 3038614741 | ||||||||
| Practice Location | |||||||||
| Address1: | 2055 HIGH ST | ||||||||
| Address2: | #130 | ||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802055503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3038612263 | ||||||||
| FaxNumber: | 3038614741 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2008 | ||||||||
| LastUpdateDate: | 05/10/2013 | ||||||||
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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 | 363AM0700X | PA740 | NV | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AM0700X | 3143 | CO | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 59271868 | 05 | CO | MEDICAID | 1760647002 | 05 | WY | MEDICAID | 201012980A | 05 | KS | MEDICAID |