Provider Demographics
NPI:1164575072
Name:BRETTHAUER, RICKY WILLIAM
Entity Type:Individual
Prefix:MR
First Name:RICKY
Middle Name:WILLIAM
Last Name:BRETTHAUER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5510 WHISKEY RIVER DR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80922-4110
Mailing Address - Country:US
Mailing Address - Phone:719-550-9196
Mailing Address - Fax:
Practice Address - Street 1:1853 OCONNELL BLVD
Practice Address - Street 2:BLDG 1042
Practice Address - City:FT CARSON
Practice Address - State:CO
Practice Address - Zip Code:80913-4055
Practice Address - Country:US
Practice Address - Phone:719-524-4670
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant