Healthcare Provider Details

I. General information

NPI: 1497872436
Provider Name (Legal Business Name): ANDREA K MALANOWSKI MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/23/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

119 CAMPUS
BOULDER CO
80309-0119
US

IV. Provider business mailing address

1042 BEREA DR
BOULDER CO
80305-6535
US

V. Phone/Fax

Practice location:
  • Phone: 303-492-5101
  • Fax:
Mailing address:
  • Phone: 303-494-8407
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number28482
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: