Healthcare Provider Details

I. General information

NPI: 1760154041
Provider Name (Legal Business Name): MEGAN MOEDE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MEGAN BRIANNA ROSA

II. Dates (important events)

Enumeration Date: 10/04/2021
Last Update Date: 10/22/2025
Certification Date: 10/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4740 PEARL PKWY STE 200
BOULDER CO
80301-3080
US

IV. Provider business mailing address

4740 PEARL PKWY STE 200
BOULDER CO
80301-3080
US

V. Phone/Fax

Practice location:
  • Phone: 303-449-2730
  • Fax:
Mailing address:
  • Phone: 303-449-2730
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA.0007594
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: