Basic Information
Provider Information | |||||||||
NPI: | 1952481970 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | JAY M. WOLKOV DO PC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | GUNNISON FAMILY MEDICAL CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 707 NORTH IOWA STREET | ||||||||
Address2: |   | ||||||||
City: | GUNNISON | ||||||||
State: | CO | ||||||||
PostalCode: | 81230 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9706411771 | ||||||||
FaxNumber: | 9706419017 | ||||||||
Practice Location | |||||||||
Address1: | 707 N IOWA ST | ||||||||
Address2: |   | ||||||||
City: | GUNNISON | ||||||||
State: | CO | ||||||||
PostalCode: | 812302229 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9706411399 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/16/2006 | ||||||||
LastUpdateDate: | 06/20/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | GELROTH | ||||||||
AuthorizedOfficialFirstName: | CYNDIE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | SPECIALIST | ||||||||
AuthorizedOfficialTelephone: | 9706411399 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | BILLING &INS | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA1940 | CO | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.