Healthcare Provider Details

I. General information

NPI: 1871984278
Provider Name (Legal Business Name): AMY HULSTROM PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/07/2015
Last Update Date: 11/01/2023
Certification Date: 11/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1925 MOUNTAIN VIEW AVE
LONGMONT CO
80501-3128
US

IV. Provider business mailing address

1925 MOUNTAIN VIEW AVE
LONGMONT CO
80501-3128
US

V. Phone/Fax

Practice location:
  • Phone: 720-494-3121
  • Fax: 720-494-3108
Mailing address:
  • Phone: 720-494-3121
  • Fax: 720-494-3108

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA.0000727
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: