Provider Demographics
NPI:1124135264
Name:NOTEBOOM, KURT DOUGLAS (PA-C, ATC)
Entity type:Individual
Prefix:
First Name:KURT
Middle Name:DOUGLAS
Last Name:NOTEBOOM
Suffix:
Gender:M
Credentials:PA-C, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8426 ZINNIA CT
Mailing Address - Street 2:
Mailing Address - City:ARVADA
Mailing Address - State:CO
Mailing Address - Zip Code:80005-1100
Mailing Address - Country:US
Mailing Address - Phone:303-952-9926
Mailing Address - Fax:303-436-3054
Practice Address - Street 1:80 HEALTH PARK DR
Practice Address - Street 2:#230
Practice Address - City:LOUISVILLE
Practice Address - State:CO
Practice Address - Zip Code:80027-9584
Practice Address - Country:US
Practice Address - Phone:303-665-2603
Practice Address - Fax:303-665-2605
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-24
Last Update Date:2008-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10057363A00000X
CO738363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN322152100Medicaid
COC810287Medicare PIN
S92470Medicare UPIN