Provider Demographics
NPI:1891957023
Name:ATHERTON, STACY MARIE (DPM)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:MARIE
Last Name:ATHERTON
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1931 65TH AVE
Mailing Address - Street 2:#A
Mailing Address - City:GREELEY
Mailing Address - State:CO
Mailing Address - Zip Code:80634-7945
Mailing Address - Country:US
Mailing Address - Phone:970-351-0900
Mailing Address - Fax:
Practice Address - Street 1:1305 SUMNER ST
Practice Address - Street 2:STE 200
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-3271
Practice Address - Country:US
Practice Address - Phone:303-772-3232
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-29
Last Update Date:2011-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDP00437213ES0103X
CO703213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO78927528Medicaid
CO78927528Medicaid