Provider Demographics
NPI:1396770871
Name:GOTHAM, CAROL FOX (NP)
Entity type:Individual
Prefix:MS
First Name:CAROL
Middle Name:FOX
Last Name:GOTHAM
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1627 E 18TH ST
Mailing Address - Street 2:
Mailing Address - City:LOVELAND
Mailing Address - State:CO
Mailing Address - Zip Code:80538-4209
Mailing Address - Country:US
Mailing Address - Phone:970-663-0135
Mailing Address - Fax:970-461-1422
Practice Address - Street 1:303 COLLAND DR
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525-4205
Practice Address - Country:US
Practice Address - Phone:970-461-8031
Practice Address - Fax:970-461-8932
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2011-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO70182363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO37526545Medicaid
COCOA105143Medicare PIN
COP32125Medicare UPIN
COC435728Medicare ID - Type Unspecified