Healthcare Provider Details

I. General information

NPI: 1538150966
Provider Name (Legal Business Name): DAVID CRISTOPHER BENNER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: DAVID BENNER PA

II. Dates (important events)

Enumeration Date: 11/03/2005
Last Update Date: 05/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 BALSAM AVE
BOULDER CO
80304-3404
US

IV. Provider business mailing address

PO BOX 173894
DENVER CO
80217-3894
US

V. Phone/Fax

Practice location:
  • Phone: 303-440-2001
  • Fax:
Mailing address:
  • Phone: 303-306-7783
  • Fax: 303-306-7753

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2965
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code364SE0003X
TaxonomyEmergency Clinical Nurse Specialist
License NumberPA17737
License Number StateCA

VII. Legacy identifiers

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

# 1
IdentifierOPA177370
Identifier TypeMEDICAID
Identifier StateCA
Identifier Issuer
# 2
Identifier36352861
Identifier TypeMEDICAID
Identifier StateCO
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: