Healthcare Provider Details

I. General information

NPI: 1629649454
Provider Name (Legal Business Name): STEPHEN FIKE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/02/2021
Last Update Date: 07/02/2021
Certification Date: 01/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 S PARKSIDE DR
COLORADO SPRINGS CO
80910-3130
US

IV. Provider business mailing address

7205 BOREAL DR
COLORADO SPRINGS CO
80915-3766
US

V. Phone/Fax

Practice location:
  • Phone: 719-572-6100
  • Fax:
Mailing address:
  • Phone: 580-678-9796
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA.0006612
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: