Healthcare Provider Details

I. General information

NPI: 1700015328
Provider Name (Legal Business Name): THOMAS BRYAN MYERS PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2009
Last Update Date: 06/18/2021
Certification Date: 06/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

580 MOHAWK DR
BOULDER CO
80303-3712
US

IV. Provider business mailing address

10350 E DAKOTA AVE
DENVER CO
80247-1314
US

V. Phone/Fax

Practice location:
  • Phone: 303-338-4545
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2803
License Number StateCO

VII. Legacy identifiers

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

# 1
Identifier022650
Identifier TypeOTHER
Identifier StateCO
Identifier IssuerKAISER COMMERCIAL NUMBER
# 2
Identifier98882376
Identifier TypeMEDICAID
Identifier StateCO
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: