Healthcare Provider Details

I. General information

NPI: 1427430032
Provider Name (Legal Business Name): MARISSA LEE FAHRBACH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MARISSSA LEE BENSON

II. Dates (important events)

Enumeration Date: 06/19/2015
Last Update Date: 03/05/2020
Certification Date: 03/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1755 48TH ST STE 100
BOULDER CO
80301-2712
US

IV. Provider business mailing address

382 S ARTHUR AVE
LOUISVILLE CO
80027-3094
US

V. Phone/Fax

Practice location:
  • Phone: 303-604-5000
  • Fax: 720-890-0364
Mailing address:
  • Phone: 303-604-5000
  • Fax: 720-890-0364

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number103068
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number557356
License Number StateKS
# 3
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number0994226
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: