Provider Demographics
NPI:1679978613
Name:JARAMILLO, JAVIER ALFONSO
Entity Type:Individual
Prefix:
First Name:JAVIER
Middle Name:ALFONSO
Last Name:JARAMILLO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:JAVIER
Other - Middle Name:A
Other - Last Name:JARAMILLO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA
Mailing Address - Street 1:2 SOUTH CASCADE AVENUE
Mailing Address - Street 2:SUITE 140
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80903-1604
Mailing Address - Country:US
Mailing Address - Phone:719-538-2900
Mailing Address - Fax:719-538-2961
Practice Address - Street 1:6025 DELMONICO DRIVE
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909
Practice Address - Country:US
Practice Address - Phone:719-535-0648
Practice Address - Fax:719-262-5574
Is Sole Proprietor?:No
Enumeration Date:2014-11-04
Last Update Date:2015-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA.0004145363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO98255312Medicaid
CO382906YMGXMedicare PIN