Basic Information
| Provider Information | |||||||||
| NPI: | 1952688780 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MANGIONE | ||||||||
| FirstName: | KRISTEN | ||||||||
| MiddleName: | L. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BJORKLUND | ||||||||
| OtherFirstName: | KRISTEN | ||||||||
| OtherMiddleName: | L | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PA-C | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 11083 COLORADO BLVD | ||||||||
| Address2: | |||||||||
| City: | FIRESTONE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805045873 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3038338880 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 11083 COLORADO BLVD | ||||||||
| Address2: | |||||||||
| City: | FIRESTONE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805045873 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3038338880 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2011 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA.0003299 | CO | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 68650582 | 05 | CO | MEDICAID |