Provider Demographics
NPI:1558330266
Name:ROBERSON, NICOLE MARIE HANNON (MD)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:MARIE HANNON
Last Name:ROBERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:MARIE
Other - Last Name:HANNON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1107 S LEMAY AVENUE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80524-3955
Mailing Address - Country:US
Mailing Address - Phone:970-493-7442
Mailing Address - Fax:970-493-7442
Practice Address - Street 1:1107 S LEMAY AVENUE
Practice Address - Street 2:SUITE 300
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80524-3955
Practice Address - Country:US
Practice Address - Phone:970-493-7442
Practice Address - Fax:970-493-7442
Is Sole Proprietor?:No
Enumeration Date:2006-03-15
Last Update Date:2020-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO47447207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN11485755OtherCAQH NUMBER
IN000000372082OtherANTHEM PROVIDER NUMBER
IN200528800Medicaid
IN9397429OtherPHCS PID NUMBER
IN9397429OtherPHCS PID NUMBER
IN000000372082OtherANTHEM PROVIDER NUMBER
INP00271686Medicare PIN
IN200528800Medicaid
IN815460BBBBMedicare PIN
IN815520MMMMMedicare PIN
IN815500K2Medicare PIN