Provider Demographics
NPI:1962960252
Name:FERGUSON, COLTON LEE
Entity type:Individual
Prefix:
First Name:COLTON
Middle Name:LEE
Last Name:FERGUSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2711 CEDARWOOD CT
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65109-9313
Mailing Address - Country:US
Mailing Address - Phone:573-821-5399
Mailing Address - Fax:
Practice Address - Street 1:2711 CEDARWOOD CT
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65109-9313
Practice Address - Country:US
Practice Address - Phone:573-821-5399
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-06
Last Update Date:2019-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program