Healthcare Provider Details

I. General information

NPI: 1053981829
Provider Name (Legal Business Name): ANNIE S MARINER PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2021
Last Update Date: 06/24/2021
Certification Date: 06/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4500 E CHERRY CREEK SOUTH DR STE 710
DENVER CO
80246-1534
US

IV. Provider business mailing address

8406 BLUEGRASS CIR
PARKER CO
80134-9281
US

V. Phone/Fax

Practice location:
  • Phone: 303-432-8487
  • Fax:
Mailing address:
  • Phone: 303-257-3409
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081P0010X
TaxonomyPediatric Rehabilitation Medicine Physician
License NumberPTA.0014984
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: