1043293921 NPI number — MRS. JAN GILLESPIE-WAGNER MD

Table of content: MRS. JAN GILLESPIE-WAGNER MD (NPI 1043293921)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043293921 NPI number — MRS. JAN GILLESPIE-WAGNER MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GILLESPIE-WAGNER
Provider First Name:
JAN
Provider Middle Name:
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GILLESPIE
Provider Other First Name:
ELIZABETH
Provider Other Middle Name:
JAN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1043293921
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/30/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1175 58TH AVE
Provider Second Line Business Mailing Address:
STE 202
Provider Business Mailing Address City Name:
GREELEY
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80634-4807
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
970-495-0300
Provider Business Mailing Address Fax Number:
970-224-9624

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1175 58TH AVE
Provider Second Line Business Practice Location Address:
STE 200
Provider Business Practice Location Address City Name:
GREELEY
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80634-4807
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
970-495-0444
Provider Business Practice Location Address Fax Number:
970-488-3106
Provider Enumeration Date:
11/23/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207L00000X , with the licence number:  26768 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208VP0014X , with the licence number: 26768 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 187075800 . This is a "DEPARTMENT OF LABOR" identifier . This identifiers is of the category "OTHER".
  • Identifier: 01267681 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 102189300 , issued by the state of ( WY ) . This identifiers is of the category "MEDICAID".
  • Identifier: GI160818 . This is a "ANTHEM BCBS" identifier , issued by the state of ( CO ) . This identifiers is of the category "OTHER".




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