Basic Information
Provider Information | |||||||||
NPI: | 1679744601 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | AYANDELE | ||||||||
FirstName: | TERESA | ||||||||
MiddleName: | M | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | WILSON | ||||||||
OtherFirstName: | TERESA | ||||||||
OtherMiddleName: | M | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 2500 S HAVANA ST | ||||||||
Address2: |   | ||||||||
City: | AURORA | ||||||||
State: | CO | ||||||||
PostalCode: | 800141618 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3033384545 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 280 EXEMPLA CIR | ||||||||
Address2: | DEPT OF ORTHOPEDICS | ||||||||
City: | LAFAYETTE | ||||||||
State: | CO | ||||||||
PostalCode: | 800263370 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3033384545 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/18/2008 | ||||||||
LastUpdateDate: | 01/17/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/17/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | 2009 | CO | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
ID | Type | State | Issuer | Description | 021242 | 01 | CO | KAISER COMMERCIAL NUMBER | OTHER | 22124349 | 05 | CO |   | MEDICAID |