Provider Demographics
NPI:1588834543
Name:HOUSLEY-KOLTER, MARIA DANETTE (PA)
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:DANETTE
Last Name:HOUSLEY-KOLTER
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 1:1 MERCADO ST
Mailing Address - Street 2:STE 160
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81301-7309
Mailing Address - Country:US
Mailing Address - Phone:303-306-7783
Mailing Address - Fax:
Practice Address - Street 1:1010 THREE SPRINGS BLVD
Practice Address - Street 2:
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81301-8296
Practice Address - Country:US
Practice Address - Phone:970-247-4311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-06
Last Update Date:2019-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO605363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO07006059Medicaid
CO300536Medicare PIN
Q32803Medicare UPIN