Healthcare Provider Details

I. General information

NPI: 1487112876
Provider Name (Legal Business Name): MARY LOUISE CHAMBERLAIN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/05/2019
Last Update Date: 02/28/2022
Certification Date: 02/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4455 E 12TH AVE
DENVER CO
80220-2415
US

IV. Provider business mailing address

4455 E 12TH AVE
DENVER CO
80220-2415
US

V. Phone/Fax

Practice location:
  • Phone: 303-504-7700
  • Fax:
Mailing address:
  • Phone: 303-504-6500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA.1433
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA.0007179
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: