Healthcare Provider Details

I. General information

NPI: 1982900833
Provider Name (Legal Business Name): DIANE ELLEN ANTIONETTE GARGUS NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/09/2011
Last Update Date: 02/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

899 MIRCOS ST
ERIE CO
80516-5411
US

IV. Provider business mailing address

899 MIRCOS ST
ERIE CO
80516-5411
US

V. Phone/Fax

Practice location:
  • Phone: 720-472-1504
  • Fax:
Mailing address:
  • Phone: 720-472-1504
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN-184415
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: