Basic Information
| Provider Information | |||||||||
| NPI: | 1588834543 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HOUSLEY-KOLTER | ||||||||
| FirstName: | MARIA | ||||||||
| MiddleName: | DANETTE | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 MERCADO ST | ||||||||
| Address2: | STE 160 | ||||||||
| City: | DURANGO | ||||||||
| State: | CO | ||||||||
| PostalCode: | 813017309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3033067783 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1010 THREE SPRINGS BLVD | ||||||||
| Address2: | |||||||||
| City: | DURANGO | ||||||||
| State: | CO | ||||||||
| PostalCode: | 813018296 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9702474311 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/06/2008 | ||||||||
| LastUpdateDate: | 02/04/2019 | ||||||||
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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 | 363A00000X | 605 | CO | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 07006059 | 05 | CO | MEDICAID |