Healthcare Provider Details

I. General information

NPI: 1164753349
Provider Name (Legal Business Name): ANNA SERGEEVNA CHUKLANOV PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/27/2010
Last Update Date: 07/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 S PARKSIDE DR
COLORADO SPRINGS CO
80910-3130
US

IV. Provider business mailing address

1364 S ZENO ST
AURORA CO
80017-4324
US

V. Phone/Fax

Practice location:
  • Phone: 719-635-7000
  • Fax:
Mailing address:
  • Phone: 303-803-2097
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number2855
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: