Basic Information
| Provider Information | |||||||||
| NPI: | 1962782037 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FUGATE | ||||||||
| FirstName: | COURTNEY | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 560825 | ||||||||
| Address2: | |||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802560825 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195957580 | ||||||||
| FaxNumber: | 7195450176 | ||||||||
| Practice Location | |||||||||
| Address1: | 400 WEST 16TH STREET | ||||||||
| Address2: | |||||||||
| City: | PUEBLO | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810032745 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195952218 | ||||||||
| FaxNumber: | 7195957994 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/22/2011 | ||||||||
| LastUpdateDate: | 10/19/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | C-APN.0000757-C-NP | CO | N | Allopathic & Osteopathic Physicians | Hospitalist | 363L00000X | 3007065 | KY | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363L00000X | C-APN.0000757-C-NP | CO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 9000145670 | 05 | CO | MEDICAID |