Basic Information
| Provider Information | |||||||||
| NPI: | 1811367139 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EARLES | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | AUSTIN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MSN, MBA, FNP-BC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | EARLES | ||||||||
| OtherFirstName: | MATTHEW | ||||||||
| OtherMiddleName: | AUSTIN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MSN, MBA, FNP-BC | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 173891 | ||||||||
| Address2: | |||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802173891 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3033067783 | ||||||||
| FaxNumber: | 3033067753 | ||||||||
| Practice Location | |||||||||
| Address1: | 1400 E BOULDER ST | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809095533 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7293655000 | ||||||||
| FaxNumber: | 3033067753 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/29/2015 | ||||||||
| LastUpdateDate: | 04/04/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 102209 | OK | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 163WE0003X | 102209 | OK | N | Nursing Service Providers | Registered Nurse | Emergency | 363L00000X | APN.0992714.NP | CO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | APN.0992714.NP | 01 | CO | NP LICENSE | OTHER |