Provider Demographics
NPI:1114256682
Name:REYNOLDS, CAROLYN WELTHER (PA-C)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:WELTHER
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:CAROLYN
Other - Middle Name:DEARDEN
Other - Last Name:WELTHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1124 E ELIZABETH ST STE C
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80524-4051
Mailing Address - Country:US
Mailing Address - Phone:970-484-0798
Mailing Address - Fax:970-482-0679
Practice Address - Street 1:1124 E ELIZABETH ST STE C
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80524-4051
Practice Address - Country:US
Practice Address - Phone:970-484-0798
Practice Address - Fax:970-482-0679
Is Sole Proprietor?:No
Enumeration Date:2009-12-13
Last Update Date:2023-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2931363A00000X, 363AM0700X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO76954382Medicaid
COCOAAA3100Medicare PIN