Healthcare Provider Details

I. General information

NPI: 1134103286
Provider Name (Legal Business Name): SUE A GRIFFITH P.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/02/2005
Last Update Date: 11/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1755 48TH ST SUITE 200
BOULDER CO
80301-2711
US

IV. Provider business mailing address

5450 WESTERN AVE
BOULDER CO
80301-2709
US

V. Phone/Fax

Practice location:
  • Phone: 303-415-7450
  • Fax: 303-494-5265
Mailing address:
  • Phone: 303-415-7450
  • Fax: 303-494-5265

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA.0000459
License Number StateCO

VII. Legacy identifiers

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

# 1
Identifier970021431
Identifier TypeOTHER
Identifier StateCO
Identifier IssuerMEDICARE RAILROAD
# 2
Identifier34189769
Identifier TypeMEDICAID
Identifier StateCO
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: