Healthcare Provider Details

I. General information

NPI: 1134726391
Provider Name (Legal Business Name): CHRISTOPHER CORAM NURSE PRACTITIONER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/01/2020
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 E RIVERWALK UNIT 200
PUEBLO CO
81003-3320
US

IV. Provider business mailing address

PO BOX 7702
LOVELAND CO
80537-0702
US

V. Phone/Fax

Practice location:
  • Phone: 195-438-3467
  • Fax: 719-545-1829
Mailing address:
  • Phone: 970-663-2742
  • Fax: 970-342-2093

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberT-APN.0000022
License Number StateCO
# 3
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberAPRN-5407
License Number StateHI
# 4
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberAPN.0996057-NP
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: