Provider Demographics
NPI:1730117086
Name:PELLOQUIN, AMY FITZGERALD (MD)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:FITZGERALD
Last Name:PELLOQUIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:J
Other - Last Name:FITZGERALD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:4674 SNOW MESA DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80528-8615
Mailing Address - Country:US
Mailing Address - Phone:970-482-3712
Mailing Address - Fax:970-266-4190
Practice Address - Street 1:4674 SNOW MESA DR
Practice Address - Street 2:SUITE 100
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80528-8615
Practice Address - Country:US
Practice Address - Phone:970-482-3712
Practice Address - Fax:970-266-4190
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2016-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARR4536207R00000X
ARR-4536207R00000X
CODR.0056652207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO86330055Medicaid
CO512431YLB8Medicare PIN
CO86330055Medicaid