Basic Information
| Provider Information | |||||||||
| NPI: | 1528056611 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PEREZ | ||||||||
| FirstName: | COURTNEY | ||||||||
| MiddleName: | BREAUX | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | RN CNM | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BREAUX | ||||||||
| OtherFirstName: | COURTNEY | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 500 ELDORADO BLVD | ||||||||
| Address2: | SUTIE 6250 | ||||||||
| City: | BROOMFIELD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800213408 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3032720768 | ||||||||
| FaxNumber: | 3033182488 | ||||||||
| Practice Location | |||||||||
| Address1: | 1960 OGDEN ST | ||||||||
| Address2: | SUITE 320 | ||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802183666 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3033182620 | ||||||||
| FaxNumber: | 3033182629 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2005 | ||||||||
| LastUpdateDate: | 12/18/2013 | ||||||||
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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 | 367A00000X | 168610 | CO | Y | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |
ID Information
| ID | Type | State | Issuer | Description | 54025079 | 01 | CO | MEDICAID GROUP NUMBER | OTHER | 98582232 | 05 | CO | MEDICAID | C300729 | 01 | CO | EXEMPLA MEDICARE PTAN | OTHER | 348308 | 01 | CO | MEDICARE GROUP # | OTHER | 37987551 | 01 | CO | MEDICAID PRACTICE GROUP # | OTHER | 810212 | 01 | CO | MEDICARE GROUP PTAN | OTHER | C810212 | 01 | CO | MEDICARE GROUP NUMBER | OTHER |