Provider Demographics
NPI:1841986494
Name:DYNAMIC ATHLETE PLLC
Entity type:Organization
Organization Name:DYNAMIC ATHLETE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:ALLISON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-997-1733
Mailing Address - Street 1:1790 30TH ST STE 270
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80301-1085
Mailing Address - Country:US
Mailing Address - Phone:303-997-1733
Mailing Address - Fax:
Practice Address - Street 1:1790 30TH ST STE 270
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80301-1085
Practice Address - Country:US
Practice Address - Phone:303-997-1733
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-04-17
Last Update Date:2025-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RS0010XAllopathic & Osteopathic PhysiciansInternal MedicineSports MedicineGroup - Single Specialty