Basic Information
| Provider Information | |||||||||
| NPI: | 1033555867 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KLEMMETSEN | ||||||||
| FirstName: | SHIELA | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | STEGORA | ||||||||
| OtherFirstName: | SHIELA | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 10700 | ||||||||
| Address2: | |||||||||
| City: | GRAND JUNCTION | ||||||||
| State: | CO | ||||||||
| PostalCode: | 815025517 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9702451220 | ||||||||
| FaxNumber: | 9702459148 | ||||||||
| Practice Location | |||||||||
| Address1: | ESSENTIA HEALTH ST. JOSEPH'S-BAXTER CLINIC | ||||||||
| Address2: | 13060 ISLE DRIVE | ||||||||
| City: | BAXTER | ||||||||
| State: | MN | ||||||||
| PostalCode: | 56425 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2188282880 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/20/2013 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | DR.0054133 | CO | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 71720103 | 05 | CO | MEDICAID |