Healthcare Provider Details

I. General information

NPI: 1063169498
Provider Name (Legal Business Name): ANDREA ORTIZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/05/2022
Last Update Date: 03/05/2022
Certification Date: 03/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7178 LONE EAGLE LN
COLORADO SPRINGS CO
80925-9579
US

IV. Provider business mailing address

7178 LONE EAGLE LN
COLORADO SPRINGS CO
80925-9579
US

V. Phone/Fax

Practice location:
  • Phone: 719-217-8208
  • Fax:
Mailing address:
  • Phone: 719-217-8208
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number206330
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: