Provider Demographics
NPI:1326396235
Name:EITEN, EMILY C
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:C
Last Name:EITEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2121 E HARMONY RD
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80528-3400
Mailing Address - Country:US
Mailing Address - Phone:970-493-6337
Mailing Address - Fax:970-493-3528
Practice Address - Street 1:2121 E HARMONY RD
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80528
Practice Address - Country:US
Practice Address - Phone:970-493-6337
Practice Address - Fax:970-493-3528
Is Sole Proprietor?:No
Enumeration Date:2012-08-27
Last Update Date:2019-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA60790428363A00000X
COPA.0005851363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1326396235Medicaid
MN970006547Medicare PIN
MNENROLLEDMedicaid