Healthcare Provider Details

I. General information

NPI: 1558811950
Provider Name (Legal Business Name): JANE GRAHAM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/10/2016
Last Update Date: 10/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1225 N GRAND AVE
PUEBLO CO
81003-2845
US

IV. Provider business mailing address

1225 N GRAND AVE
PUEBLO CO
81003-2845
US

V. Phone/Fax

Practice location:
  • Phone: 719-546-3511
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0992502-NP
License Number StateCO

VIII. Authorized Official

Name: ANTHONY ORTEGON
Title or Position: PRESIDENT
Credential: M.D.
Phone: 719-546-3511