Provider Demographics
NPI:1184338147
Name:AUSTIN, TSOMORLOG
Entity type:Individual
Prefix:
First Name:TSOMORLOG
Middle Name:
Last Name:AUSTIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7758 HIGH GATE DR
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN
Mailing Address - State:CO
Mailing Address - Zip Code:80817-4232
Mailing Address - Country:US
Mailing Address - Phone:414-364-4156
Mailing Address - Fax:
Practice Address - Street 1:110 E ROUTT AVE
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81004-2117
Practice Address - Country:US
Practice Address - Phone:719-543-8711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-12
Last Update Date:2023-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COAPN.0998362-NP363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner