Provider Demographics
NPI:1174660534
Name:BABCOCK, TERRA (PA)
Entity Type:Individual
Prefix:
First Name:TERRA
Middle Name:
Last Name:BABCOCK
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:151 W LAKE ST STE 1500
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80524-4124
Mailing Address - Country:US
Mailing Address - Phone:970-237-8200
Mailing Address - Fax:970-237-8291
Practice Address - Street 1:151 W LAKE ST STE 1500
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80524
Practice Address - Country:US
Practice Address - Phone:970-237-8200
Practice Address - Fax:970-237-8291
Is Sole Proprietor?:No
Enumeration Date:2007-02-01
Last Update Date:2018-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1337363A00000X
IL085002881363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO90478339Medicaid
CO90478339Medicaid
COCO303823Medicare PIN
IL0533210001OtherDMERC
ILK36751Medicare PIN
COCOA102270Medicare PIN