Provider Demographics
NPI:1205960234
Name:VASTENBURG, ANTOINETTE (PT)
Entity type:Individual
Prefix:
First Name:ANTOINETTE
Middle Name:
Last Name:VASTENBURG
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:470 GOLD RUN RD
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80302-8743
Mailing Address - Country:US
Mailing Address - Phone:303-447-9312
Mailing Address - Fax:
Practice Address - Street 1:4150 DARLEY AVE
Practice Address - Street 2:SUITE8
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80305-6557
Practice Address - Country:US
Practice Address - Phone:303-494-4100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2017-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO3608225100000X, 2251S0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO64770095Medicaid
COC459868Medicare PIN
CO64770095Medicaid