1770536344 NPI number — MRS. HEATHER J KOHOUT PA-C

Table of content: MRS. HEATHER J KOHOUT PA-C (NPI 1770536344)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770536344 NPI number — MRS. HEATHER J KOHOUT PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KOHOUT
Provider First Name:
HEATHER
Provider Middle Name:
J
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
VATLAND
Provider Other First Name:
HEATHER
Provider Other Middle Name:
J
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA-C
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1770536344
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/13/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8550 W 38TH AVE STE 300
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WHEAT RIDGE
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80033-4355
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
303-463-3900
Provider Business Mailing Address Fax Number:
303-423-2621

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8550 W 38TH AVE STE 300
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WHEAT RIDGE
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80033-4355
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
303-463-3900
Provider Business Practice Location Address Fax Number:
303-423-2621
Provider Enumeration Date:
05/18/2006

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: 363A00000X , with the licence number:  3430 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: 085002714 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: 85002714 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 809840 . This is a "MEDICARE GROUP" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: CA4079 . This is a "RR MEDICARE GROUP PTAN" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 371221637 . This is a "FEDERAL TAX ID" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 776530 . This is a "MEDICARE GROUP PIN" identifier . This identifiers is of the category "OTHER".
  • Identifier: P00680137 . This is a "RR MEDICARE MEMBER PTAN" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".