Healthcare Provider Details

I. General information

NPI: 1386919793
Provider Name (Legal Business Name): LAURA BETH HUNDEMANN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2012
Last Update Date: 09/14/2022
Certification Date: 09/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2919 VALMONT RD STE 204
BOULDER CO
80301-1350
US

IV. Provider business mailing address

2919 VALMONT RD # 204
BOULDER CO
80301-1350
US

V. Phone/Fax

Practice location:
  • Phone: 303-938-1110
  • Fax: 303-938-1145
Mailing address:
  • Phone: 303-938-1110
  • Fax: 303-938-1145

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number3395
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: