Healthcare Provider Details

I. General information

NPI: 1285168823
Provider Name (Legal Business Name): SUZANNE DYSART
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2017
Last Update Date: 11/18/2025
Certification Date: 11/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4745 ARAPAHOE AVE STE 320
BOULDER CO
80303-1082
US

IV. Provider business mailing address

PO BOX 9049
BOULDER CO
80301-9049
US

V. Phone/Fax

Practice location:
  • Phone: 303-441-0587
  • Fax: 303-996-0801
Mailing address:
  • Phone: 303-415-4101
  • Fax: 303-415-4101

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberDR.0071119
License Number StateCO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier9000222080
Identifier TypeMEDICAID
Identifier StateCO
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: