Provider Demographics
NPI:1043389356
Name:AMMON, ANGELA (MD)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:AMMON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 0129
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:CO
Mailing Address - Zip Code:81631-0129
Mailing Address - Country:US
Mailing Address - Phone:970-328-6357
Mailing Address - Fax:970-328-5633
Practice Address - Street 1:377 SYLVAN LAKE RD STE 220
Practice Address - Street 2:
Practice Address - City:EAGLE
Practice Address - State:CO
Practice Address - Zip Code:81631-0129
Practice Address - Country:US
Practice Address - Phone:970-328-6357
Practice Address - Fax:970-328-5633
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2008-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COCO35669207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01356690Medicaid
CO1043389356OtherNPI
COCO35669OtherLICENSE
CU5658Medicare Oscar/Certification
CU5658Medicare PIN
COCO35669OtherLICENSE