Provider Demographics
NPI:1689207029
Name:STRAIGHT-BRAKER, KARLIE (PA)
Entity type:Individual
Prefix:
First Name:KARLIE
Middle Name:
Last Name:STRAIGHT-BRAKER
Suffix:
Gender:
Credentials:PA
Other - Prefix:
Other - First Name:KARLIE
Other - Middle Name:
Other - Last Name:STRAIGHT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:2 FRIAR TUCK WAY
Mailing Address - Street 2:
Mailing Address - City:BERLIN
Mailing Address - State:MD
Mailing Address - Zip Code:21811-2044
Mailing Address - Country:US
Mailing Address - Phone:443-880-0660
Mailing Address - Fax:
Practice Address - Street 1:1120 E ELIZABETH ST STE G2
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80524-4044
Practice Address - Country:US
Practice Address - Phone:970-493-9193
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-13
Last Update Date:2025-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA.0006707363A00000X, 207QA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
No207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction MedicineGroup - Single Specialty