Basic Information
| Provider Information | |||||||||
| NPI: | 1770557993 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TIETSORT | ||||||||
| FirstName: | BROOKE | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7851 S ELATI ST | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | LITTLETON | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801208080 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3037590854 | ||||||||
| FaxNumber: | 3037590864 | ||||||||
| Practice Location | |||||||||
| Address1: | 4231 W 16TH AVE | ||||||||
| Address2: | |||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802041335 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3036293721 | ||||||||
| FaxNumber: | 3036292192 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 2000 | CO | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 51026023 | 05 | CO | MEDICAID |