Basic Information
| Provider Information | |||||||||
| NPI: | 1922339431 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | UTTLEY | ||||||||
| FirstName: | BRANDON | ||||||||
| MiddleName: | M | ||||||||
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| OtherLastName: | UTTLEY | ||||||||
| OtherFirstName: | BRANDON | ||||||||
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| OtherCredential: | PA-C | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 1175 | ||||||||
| Address2: | |||||||||
| City: | ENGLEWOOD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801501175 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3033067783 | ||||||||
| FaxNumber: | 3033067753 | ||||||||
| Practice Location | |||||||||
| Address1: | 1950 MOUNTAIN VIEW AVE | ||||||||
| Address2: | |||||||||
| City: | LONGMONT | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805013129 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3033067783 | ||||||||
| FaxNumber: | 3033067753 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/22/2010 | ||||||||
| LastUpdateDate: | 02/26/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | 2831 | CO | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363A00000X | 2831 | CO | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 71681531 | 05 | CO | MEDICAID | P00842822 | 01 | CO | RAILROAD MEDICARE PIN | OTHER |