Provider Demographics
NPI:1710156278
Name:DEAN, AUTUMN NICOLE (MD)
Entity Type:Individual
Prefix:DR
First Name:AUTUMN
Middle Name:NICOLE
Last Name:DEAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2695 ROCKY MOUNTAIN AVE
Mailing Address - Street 2:STE 150
Mailing Address - City:LOVELAND
Mailing Address - State:CO
Mailing Address - Zip Code:80538-9071
Mailing Address - Country:US
Mailing Address - Phone:970-624-4036
Mailing Address - Fax:970-490-4378
Practice Address - Street 1:101 BODIN CIR
Practice Address - Street 2:
Practice Address - City:TRAVIS AFB
Practice Address - State:CA
Practice Address - Zip Code:94535-1809
Practice Address - Country:US
Practice Address - Phone:707-423-3067
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-28
Last Update Date:2016-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101242249207Q00000X
CODR.0051716207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO87132753Medicaid