Healthcare Provider Details

I. General information

NPI: 1962408021
Provider Name (Legal Business Name): ANNA T ROE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2005
Last Update Date: 11/10/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4743 ARAPAHOE AVE SUITE 201
BOULDER CO
80303-1113
US

IV. Provider business mailing address

5450 WESTERN AVE SUITE B
BOULDER CO
80301-2709
US

V. Phone/Fax

Practice location:
  • Phone: 303-442-2395
  • Fax: 303-442-1073
Mailing address:
  • Phone: 303-442-2395
  • Fax: 303-442-1073

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number878
License Number StateCO

VII. Legacy identifiers

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

# 1
Identifier07008782
Identifier TypeMEDICAID
Identifier StateCO
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: