Provider Demographics
NPI:1831122068
Name:ROTHBAUM, YURI C (PA)
Entity Type:Individual
Prefix:
First Name:YURI
Middle Name:C
Last Name:ROTHBAUM
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:YURI
Other - Middle Name:C
Other - Last Name:ROTHBAUM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 173891
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80217-3891
Mailing Address - Country:US
Mailing Address - Phone:719-365-5000
Mailing Address - Fax:719-365-6827
Practice Address - Street 1:1400 E BOULDER ST
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:719-560-5656
Practice Address - Fax:719-560-4715
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA.0001060207P00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1060OtherCOLORADO LICENSE
P00065901OtherRAILROAD MEDICARE
CO35288876Medicaid
CO35288876Medicaid
COC489238Medicare PIN
P00065901OtherRAILROAD MEDICARE