Provider Demographics
NPI:1992350193
Name:STREET, VIKTORIYA
Entity type:Individual
Prefix:
First Name:VIKTORIYA
Middle Name:
Last Name:STREET
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203 S ROLLIE AVE
Mailing Address - Street 2:
Mailing Address - City:FORT LUPTON
Mailing Address - State:CO
Mailing Address - Zip Code:80621-1508
Mailing Address - Country:US
Mailing Address - Phone:303-892-6401
Mailing Address - Fax:
Practice Address - Street 1:1950 REDTAIL HAWK DR
Practice Address - Street 2:
Practice Address - City:ESTES PARK
Practice Address - State:CO
Practice Address - Zip Code:80517-9780
Practice Address - Country:US
Practice Address - Phone:303-697-2583
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-05
Last Update Date:2024-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA.0007908363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant