Healthcare Provider Details

I. General information

NPI: 1730361445
Provider Name (Legal Business Name): PATRICIA WYNN HENMAN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/04/2007
Last Update Date: 12/11/2023
Certification Date: 12/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

777 29TH ST STE 301
BOULDER CO
80303-2316
US

IV. Provider business mailing address

777 29TH ST STE 301
BOULDER CO
80303-2316
US

V. Phone/Fax

Practice location:
  • Phone: 303-440-8243
  • Fax: 303-440-0292
Mailing address:
  • Phone: 303-440-8243
  • Fax: 303-440-0292

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2521
License Number StateCO
# 3
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number2521
License Number StateCO

VII. Legacy identifiers

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: