Basic Information
| Provider Information | |||||||||
| NPI: | 1124068291 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WOJTKOWSKI KHAN-FAROOQI | ||||||||
| FirstName: | THEA | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WOJTKOWSKI | ||||||||
| OtherFirstName: | THEA | ||||||||
| OtherMiddleName: | A | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 181 W MEADOW DR | ||||||||
| Address2: | STE 400 | ||||||||
| City: | VAIL | ||||||||
| State: | CO | ||||||||
| PostalCode: | 816575058 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9704761100 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 627 25 1/2 RD | ||||||||
| Address2: | |||||||||
| City: | GRAND JUNCTION | ||||||||
| State: | CO | ||||||||
| PostalCode: | 815056401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9702423535 | ||||||||
| FaxNumber: | 9706238599 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2006 | ||||||||
| LastUpdateDate: | 11/25/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/25/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | MD00044171 | WA | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207X00000X | 47982 | CO | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 41208030 | 05 | CO | MEDICAID | CO306351 | 01 | CO | MEDICARE PTAN | OTHER | 8447393 | 05 | WA | MEDICAID |