Basic Information
| Provider Information | |||||||||
| NPI: | 1164783536 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HEATON | ||||||||
| FirstName: | ALYSSA | ||||||||
| MiddleName: | NICOLE | ||||||||
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| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | RATZLAFF | ||||||||
| OtherFirstName: | ALYSSA | ||||||||
| OtherMiddleName: | NICOLE | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 173891 | ||||||||
| Address2: | |||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802173891 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3033067783 | ||||||||
| FaxNumber: | 3033067753 | ||||||||
| Practice Location | |||||||||
| Address1: | 1400 E BOULDER ST | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809095533 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7193655000 | ||||||||
| FaxNumber: | 3033067753 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2012 | ||||||||
| LastUpdateDate: | 08/27/2015 | ||||||||
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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 | 390200000X | 182928 | NC | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207P00000X | DR.0055387 | CO | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 86103008 | 05 | CO | MEDICAID |