Basic Information
Provider Information | |||||||||
NPI: | 1861597288 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | TESCHNER | ||||||||
FirstName: | SUE | ||||||||
MiddleName: | LYNNE | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | BOLTE | ||||||||
OtherFirstName: | SUE | ||||||||
OtherMiddleName: | LYNNE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PA-C | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 2 S CASCADE AVE STE 140 | ||||||||
Address2: |   | ||||||||
City: | COLORADO SPRINGS | ||||||||
State: | CO | ||||||||
PostalCode: | 809031604 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7195382950 | ||||||||
FaxNumber: | 7195382999 | ||||||||
Practice Location | |||||||||
Address1: | 2610 TENDERFOOT HILL ST | ||||||||
Address2: |   | ||||||||
City: | COLORADO SPRINGS | ||||||||
State: | CO | ||||||||
PostalCode: | 80906 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7195221133 | ||||||||
FaxNumber: | 7192268681 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/13/2006 | ||||||||
LastUpdateDate: | 06/13/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA.0004415 | CO | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
ID | Type | State | Issuer | Description | 1041493 | 01 |   | NCCPA NUMBER | OTHER | PA.0004415 | 01 | CO | CO MED LICENSE | OTHER | 9000162218 | 05 | CO |   | MEDICAID |