Provider Demographics
NPI:1043293921
Name:GILLESPIE-WAGNER, JAN (MD)
Entity Type:Individual
Prefix:MRS
First Name:JAN
Middle Name:
Last Name:GILLESPIE-WAGNER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:JAN
Other - Last Name:GILLESPIE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1175 58TH AVE
Mailing Address - Street 2:STE 202
Mailing Address - City:GREELEY
Mailing Address - State:CO
Mailing Address - Zip Code:80634-4807
Mailing Address - Country:US
Mailing Address - Phone:970-495-0300
Mailing Address - Fax:970-224-9624
Practice Address - Street 1:1175 58TH AVE
Practice Address - Street 2:STE 200
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80634-4807
Practice Address - Country:US
Practice Address - Phone:970-495-0444
Practice Address - Fax:970-488-3106
Is Sole Proprietor?:No
Enumeration Date:2005-11-23
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO26768207L00000X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
187075800OtherDEPARTMENT OF LABOR
CO01267681Medicaid
WY102189300Medicaid
COGI160818OtherANTHEM BCBS