Healthcare Provider Details

I. General information

NPI: 1811447451
Provider Name (Legal Business Name): MADELINE LUSK PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2016
Last Update Date: 08/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1725 E BOULDER ST STE 101
COLORADO SPRINGS CO
80909
US

IV. Provider business mailing address

2695 ROCKY MOUNTAIN AVE STE 150
LOVELAND CO
80538-9071
US

V. Phone/Fax

Practice location:
  • Phone: 719-365-6300
  • Fax: 719-365-6094
Mailing address:
  • Phone: 970-624-4034
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberMA058586
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberMA058586
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA.0005909
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: