Basic Information
| Provider Information | |||||||||
| NPI: | 1598995417 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARTIN | ||||||||
| FirstName: | AUTUMN | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MS,FNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KELLER | ||||||||
| OtherFirstName: | AUTUMN | ||||||||
| OtherMiddleName: | MARIE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MS,FNP | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 900 CEDAR ST | ||||||||
| Address2: | |||||||||
| City: | JULESBURG | ||||||||
| State: | CO | ||||||||
| PostalCode: | 807371121 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9703539403 | ||||||||
| FaxNumber: | 9703539906 | ||||||||
| Practice Location | |||||||||
| Address1: | 900 CEDAR ST | ||||||||
| Address2: | |||||||||
| City: | JULESBURG | ||||||||
| State: | CO | ||||||||
| PostalCode: | 807371121 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9703539403 | ||||||||
| FaxNumber: | 9703539906 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2009 | ||||||||
| LastUpdateDate: | 05/10/2016 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | NP10050 | CO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 84427060 | 05 | CO | MEDICAID |