Healthcare Provider Details

I. General information

NPI: 1205265774
Provider Name (Legal Business Name): NATASHA ELLWOOD PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/05/2013
Last Update Date: 06/07/2022
Certification Date: 06/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 EMMA RD
BASALT CO
81621-9169
US

IV. Provider business mailing address

1905 BLAKE AVE STE 101
GLENWOOD SPRINGS CO
81601-4206
US

V. Phone/Fax

Practice location:
  • Phone: 970-945-2840
  • Fax: 970-945-2893
Mailing address:
  • Phone: 970-945-2840
  • Fax: 970-945-2893

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number840793217
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number3850
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: