Healthcare Provider Details

I. General information

NPI: 1417992132
Provider Name (Legal Business Name): GOLDA REISDORPH PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2006
Last Update Date: 02/05/2025
Certification Date: 02/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2405 RESEARCH PKWY
COLORADO SPRINGS CO
80920-1044
US

IV. Provider business mailing address

PO BOX 35380
LAS VEGAS NV
89133-5380
US

V. Phone/Fax

Practice location:
  • Phone: 719-574-9191
  • Fax:
Mailing address:
  • Phone: 719-538-2900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number1301
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA.0001301
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: