Healthcare Provider Details

I. General information

NPI: 1154780757
Provider Name (Legal Business Name): MICHAEL K CHISM II PMHNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/11/2016
Last Update Date: 08/20/2024
Certification Date: 08/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2675 S ABILENE ST STE 100
AURORA CO
80014-2363
US

IV. Provider business mailing address

15355 E COLFAX AVE UNIT 111717
AURORA CO
80042-1975
US

V. Phone/Fax

Practice location:
  • Phone: 720-507-4779
  • Fax: 833-941-5047
Mailing address:
  • Phone: 720-507-4779
  • Fax: 720-367-5067

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPN.0992884-NP
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: