Provider Demographics
NPI:1699191536
Name:FORTENBAUGH, MELINDA (PA)
Entity type:Individual
Prefix:
First Name:MELINDA
Middle Name:
Last Name:FORTENBAUGH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:MELINDA
Other - Middle Name:
Other - Last Name:BOLGAR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:10350 E DAKOTA AVE
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80247-1314
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4105 BRIARGATE PKWY STE 125
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80920-3482
Practice Address - Country:US
Practice Address - Phone:303-338-4545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-17
Last Update Date:2021-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9107828363A00000X
COPA.0005559363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1116613OtherNCCPA