Healthcare Provider Details

I. General information

NPI: 1619286424
Provider Name (Legal Business Name): AMY WYATT ROSENBLUM PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: AMY LYNN WYATT

II. Dates (important events)

Enumeration Date: 09/28/2010
Last Update Date: 01/27/2025
Certification Date: 01/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

955 LAWRENCE WAY SUITE 150
DENVER CO
80204
US

IV. Provider business mailing address

PO BOX 173362
DENVER CO
80217-3362
US

V. Phone/Fax

Practice location:
  • Phone: 303-615-9999
  • Fax: 720-778-5850
Mailing address:
  • Phone: 303-615-9999
  • Fax: 720-778-5850

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDT07529
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: