Basic Information
Provider Information | |||||||||
NPI: | 1346560562 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HOFER | ||||||||
FirstName: | ANNE | ||||||||
MiddleName: | CATHERINE | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2930 11TH AVE | ||||||||
Address2: |   | ||||||||
City: | EVANS | ||||||||
State: | CO | ||||||||
PostalCode: | 806201011 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9703539403 | ||||||||
FaxNumber: | 9703504645 | ||||||||
Practice Location | |||||||||
Address1: | 2930 11TH AVE | ||||||||
Address2: |   | ||||||||
City: | EVANS | ||||||||
State: | CO | ||||||||
PostalCode: | 806201011 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9703539403 | ||||||||
FaxNumber: | 9703504645 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/10/2010 | ||||||||
LastUpdateDate: | 06/30/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | BP10037210 | TX | N |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   | 261QF0400X | 50943 | CO | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
ID | Type | State | Issuer | Description | 93902573 | 05 | CO |   | MEDICAID |