Provider Demographics
NPI:1306481734
Name:GUNDERSEN, NICOLE (PA-C)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:GUNDERSEN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7702
Mailing Address - Street 2:
Mailing Address - City:LOVELAND
Mailing Address - State:CO
Mailing Address - Zip Code:80537-0702
Mailing Address - Country:US
Mailing Address - Phone:970-663-2742
Mailing Address - Fax:970-342-2093
Practice Address - Street 1:175 S UNION BLVD STE 200
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80910-3117
Practice Address - Country:US
Practice Address - Phone:719-372-5555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-08
Last Update Date:2021-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant