MEDICARE: NICOLE MARIE HANNON ROBERSON MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207V00000X	Obstetrics & Gynecology Physician	47447	CO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	11485755	OTHER	IN	CAQH NUMBER
2	000000372082	OTHER	IN	ANTHEM PROVIDER NUMBER
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	9397429	OTHER	IN	PHCS PID NUMBER

General Provider Information

NPI Number	:	1558330266
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLE MARIE HANNON ROBERSON MD

Provider Business Mailing Address
First Line	:	1107 S LEMAY AVENUE
Second Line	:	SUITE 300
City	:	FORT COLLINS
State	:	CO
Zip	:	80524-3955
Country	:	US
Telephone Number	:	970-493-7442
Fax Number	:	970-493-7442

Provider Business Practice Location Address
First Line	:	1107 S LEMAY AVENUE
Second Line	:	SUITE 300
City	:	FORT COLLINS
State	:	CO
Zip	:	80524-3955
Country	:	US
Telephone Number	:	970-493-7442
Fax Number	:	970-493-7442

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/15/2006
Last Update Date	:	03/10/2020

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