Provider Demographics
NPI:1720394612
Name:MANTILLA-ACEVEDO, JOSE G (NP)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:G
Last Name:MANTILLA-ACEVEDO
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
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Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:1035 GARDEN OF THE GODS RD
Mailing Address - Street 2:SUITE 120
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80907-9427
Mailing Address - Country:US
Mailing Address - Phone:719-329-1000
Mailing Address - Fax:719-598-0807
Practice Address - Street 1:1035 GARDEN OF THE GODS RD
Practice Address - Street 2:SUITE 120
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80907-9427
Practice Address - Country:US
Practice Address - Phone:719-329-1000
Practice Address - Fax:719-598-0807
Is Sole Proprietor?:No
Enumeration Date:2010-08-30
Last Update Date:2016-09-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL209008328363LF0000X
IL041363059163W00000X
COAPN.0991852-NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse