Healthcare Provider Details

I. General information

NPI: 1679756431
Provider Name (Legal Business Name): PEDIATRIC ASSOCIATES OF DURANGO, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/14/2007
Last Update Date: 01/17/2025
Certification Date: 01/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29423 HIGHWAY 160
DURANGO CO
81301-7939
US

IV. Provider business mailing address

29423 HIGHWAY 160
DURANGO CO
81301-7939
US

V. Phone/Fax

Practice location:
  • Phone: 970-259-7337
  • Fax: 970-259-7366
Mailing address:
  • Phone: 970-259-7337
  • Fax: 970-259-7366

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number42100
License Number StateCO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: STACY BOWER
Title or Position: PRESIDENT
Credential:
Phone: 970-259-7337