Provider Demographics
NPI:1205265774
Name:ELLWOOD, NATASHA (PA)
Entity type:Individual
Prefix:
First Name:NATASHA
Middle Name:
Last Name:ELLWOOD
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1905 BLAKE AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:GLENWOOD SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:81601-4206
Mailing Address - Country:US
Mailing Address - Phone:970-945-2840
Mailing Address - Fax:970-945-2893
Practice Address - Street 1:123 EMMA RD
Practice Address - Street 2:
Practice Address - City:BASALT
Practice Address - State:CO
Practice Address - Zip Code:81621-9169
Practice Address - Country:US
Practice Address - Phone:970-945-2840
Practice Address - Fax:970-945-2893
Is Sole Proprietor?:No
Enumeration Date:2013-11-05
Last Update Date:2022-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO840793217174400000X
CO3850363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO63970236Medicaid
CO457026YKNXMedicare PIN