MEDICARE: STACEY EDWARDS PTA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225200000X	Physical Therapy Assistant	12391	CO

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	12391	OTHER	CO	MEDICARE

General Provider Information

NPI Number	:	1174867295
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STACEY EDWARDS PTA

Provider Business Mailing Address
First Line	:	3737 LANDINGS DR
Second Line	:	A4
City	:	FORT COLLINS
State	:	CO
Zip	:	80525-3159
Country	:	US
Telephone Number	:	720-299-4458
Fax Number	:

Provider Business Practice Location Address
First Line	:	3737 LANDINGS DR
Second Line	:	A4
City	:	FORT COLLINS
State	:	CO
Zip	:	80525-3159
Country	:	US
Telephone Number	:	720-299-4458
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/15/2012
Last Update Date	:	11/15/2012

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