1952397952 NPI number — DAWN LESLIE EVERT NP

Table of content: TRAVIS T WILLIAMS DPT (NPI 1720375744)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1952397952 NPI number — DAWN LESLIE EVERT NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EVERT
Provider First Name:
DAWN
Provider Middle Name:
LESLIE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CARLOCK
Provider Other First Name:
DAWN
Provider Other Middle Name:
LESLIE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
RN
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1952397952
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/05/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
900 INDIANA AVE STE D
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PUEBLO
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
81004-3767
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
719-924-9021
Provider Business Mailing Address Fax Number:
719-924-9166

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
900 INDIANA AVE STE D
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PUEBLO
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
81004-3767
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
719-924-9021
Provider Business Practice Location Address Fax Number:
719-924-9166
Provider Enumeration Date:
09/25/2005

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: 363LF0000X , with the licence number:  4650 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 163W00000X , with the licence number: 81123 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 87339056 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".