Provider Demographics
NPI:1124068291
Name:WOJTKOWSKI KHAN-FAROOQI, THEA A (MD)
Entity type:Individual
Prefix:
First Name:THEA
Middle Name:A
Last Name:WOJTKOWSKI KHAN-FAROOQI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:THEA
Other - Middle Name:A
Other - Last Name:WOJTKOWSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:181 W MEADOW DR
Mailing Address - Street 2:STE 400
Mailing Address - City:VAIL
Mailing Address - State:CO
Mailing Address - Zip Code:81657-5058
Mailing Address - Country:US
Mailing Address - Phone:970-476-1100
Mailing Address - Fax:
Practice Address - Street 1:627 25 1/2 RD
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81505-6401
Practice Address - Country:US
Practice Address - Phone:970-242-3535
Practice Address - Fax:970-623-8599
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2020-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00044171207X00000X
CO47982207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO41208030Medicaid
COCO306351OtherMEDICARE PTAN
WA8447393Medicaid
WA8859030Medicare ID - Type Unspecified
WA8447393Medicaid