1275858334 NPI number — MS. ANTWONETTE MIXON PROTHRO NCPT

Table of content: MS. ANTWONETTE MIXON PROTHRO NCPT (NPI 1275858334)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275858334 NPI number — MS. ANTWONETTE MIXON PROTHRO NCPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PROTHRO
Provider First Name:
ANTWONETTE
Provider Middle Name:
MIXON
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
NCPT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1275858334
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/01/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4340 E. KENTUCKY AVENUE
Provider Second Line Business Mailing Address:
SUITE 462
Provider Business Mailing Address City Name:
GLENDALE
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80246
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
303-815-1914
Provider Business Mailing Address Fax Number:
303-815-1915

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4340 E KENTUCKY AVE
Provider Second Line Business Practice Location Address:
SUITE 462
Provider Business Practice Location Address City Name:
GLENDALE
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80246-2060
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
303-815-1914
Provider Business Practice Location Address Fax Number:
303-815-1915
Provider Enumeration Date:
04/01/2010

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: 246RP1900X , with the licence number:  091720 , 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)





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