Provider Demographics
NPI:1639655079
Name:KLUTZ, STEPHANIE JO (PA-C)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:JO
Last Name:KLUTZ
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:JO
Other - Last Name:BROLSMA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:2535 S DOWNING ST STE 180F
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80210-5847
Mailing Address - Country:US
Mailing Address - Phone:303-762-0808
Mailing Address - Fax:303-762-9292
Practice Address - Street 1:2535 S DOWNING ST STE 180F
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80210-5847
Practice Address - Country:US
Practice Address - Phone:303-762-0808
Practice Address - Fax:303-762-9292
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-18
Last Update Date:2020-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA.0005428363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
COPA.0005428OtherCOLORADO DEPARTMENT OF REGULATORY AGENCIES
1152106OtherNCCPA