Provider Demographics
NPI:1720571201
Name:MADDOX, ELIZABETH RENEE (AA)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:RENEE
Last Name:MADDOX
Suffix:
Gender:F
Credentials:AA
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:
Other - Last Name:GAMBILL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 840862
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-0862
Mailing Address - Country:US
Mailing Address - Phone:303-377-7638
Mailing Address - Fax:303-780-0787
Practice Address - Street 1:8000 E MAPLEWOOD AVE STE 120
Practice Address - Street 2:
Practice Address - City:GREENWOOD VILLAGE
Practice Address - State:CO
Practice Address - Zip Code:80111-4766
Practice Address - Country:US
Practice Address - Phone:303-438-3999
Practice Address - Fax:720-439-9500
Is Sole Proprietor?:No
Enumeration Date:2018-06-11
Last Update Date:2023-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COANT.0000186367H00000X
367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2018019006OtherMO LICENSE