Provider Demographics
NPI:1295247393
Name:STATER, ADAM (AG-ACNP, MSN, RN)
Entity type:Individual
Prefix:
First Name:ADAM
Middle Name:
Last Name:STATER
Suffix:
Gender:M
Credentials:AG-ACNP, MSN, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2121 E HARMONY RD UNIT 160
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80528-3413
Mailing Address - Country:US
Mailing Address - Phone:970-482-3328
Mailing Address - Fax:970-482-1433
Practice Address - Street 1:2121 E HARMONY RD UNIT 160
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80528-3413
Practice Address - Country:US
Practice Address - Phone:970-482-3328
Practice Address - Fax:970-482-1433
Is Sole Proprietor?:No
Enumeration Date:2017-10-30
Last Update Date:2024-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COAPN.0998550-NP363LA2100X
TN23400363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000197411Medicaid