Provider Demographics
NPI:1639543317
Name:ALTHOUSE, MICHELLE AMANDA (PA)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:AMANDA
Last Name:ALTHOUSE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:AMANDA
Other - Last Name:ROLL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3455 LUTHERAN PKWY STE 105
Mailing Address - Street 2:
Mailing Address - City:WHEAT RIDGE
Mailing Address - State:CO
Mailing Address - Zip Code:80033-6028
Mailing Address - Country:US
Mailing Address - Phone:303-665-2603
Mailing Address - Fax:303-665-2605
Practice Address - Street 1:500 W 144TH AVE STE 230
Practice Address - Street 2:
Practice Address - City:WESTMINSTER
Practice Address - State:CO
Practice Address - Zip Code:80023-9328
Practice Address - Country:US
Practice Address - Phone:303-665-2603
Practice Address - Fax:303-665-2605
Is Sole Proprietor?:No
Enumeration Date:2015-11-18
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA.0004461363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant