Provider Demographics
NPI:1376672485
Name:SHATTUCK, COLLEEN M (PAC)
Entity Type:Individual
Prefix:MRS
First Name:COLLEEN
Middle Name:M
Last Name:SHATTUCK
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6455 S YOSEMITE ST
Mailing Address - Street 2:#600
Mailing Address - City:GREENWOOD VILLAGE
Mailing Address - State:CO
Mailing Address - Zip Code:80111-5139
Mailing Address - Country:US
Mailing Address - Phone:303-710-2013
Mailing Address - Fax:855-244-2146
Practice Address - Street 1:6455 S YOSEMITE ST
Practice Address - Street 2:#600
Practice Address - City:GREENWOOD VILLAGE
Practice Address - State:CO
Practice Address - Zip Code:80111-5139
Practice Address - Country:US
Practice Address - Phone:303-710-2013
Practice Address - Fax:855-244-2146
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2015-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1660363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO09738207Medicaid
COC801351Medicare PIN
CO09738207Medicaid