1356505135 NPI number — SHASTA ROANN VAN SICKLE PA-C

Table of content: SHASTA ROANN VAN SICKLE PA-C (NPI 1356505135)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356505135 NPI number — SHASTA ROANN VAN SICKLE PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VAN SICKLE
Provider First Name:
SHASTA
Provider Middle Name:
ROANN
Provider Name Prefix Text:
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:
BEAL
Provider Other First Name:
SHASTA
Provider Other Middle Name:
ROANN
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:
1356505135
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/24/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2801 PURCELL ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BRIGHTON
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80601-3551
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
303-659-9700
Provider Business Mailing Address Fax Number:
303-558-8222

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
660 GOLDEN RIDGE RD
Provider Second Line Business Practice Location Address:
STE. 250
Provider Business Practice Location Address City Name:
GOLDEN
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80401-9541
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
303-233-1223
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/11/2008

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 ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1356505135 , issued by the state of ( SD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 55036724 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".




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