1114994779 NPI number — COLLEEN E WOLF PA-C

Table of content: COLLEEN E WOLF PA-C (NPI 1114994779)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114994779 NPI number — COLLEEN E WOLF PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WOLF
Provider First Name:
COLLEEN
Provider Middle Name:
E
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:
KINDSCHI
Provider Other First Name:
COLLEEN
Provider Other Middle Name:
E
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PAC
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1114994779
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/15/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4674 SNOW MESA DR
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
FORT COLLINS
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80528-8615
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
970-495-8450
Provider Business Mailing Address Fax Number:
970-297-6599

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2810 KENNEDY DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BELOIT
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53511
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
608-361-5872
Provider Business Practice Location Address Fax Number:
608-365-5980
Provider Enumeration Date:
03/02/2006

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:  3432 , 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: 55183778 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".
  • Identifier: P01084733 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( CO ) . This identifiers is of the category "OTHER".




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