Healthcare Provider Details

I. General information

NPI: 1508655721
Provider Name (Legal Business Name): AVERY MARIE TUDOR PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2025
Last Update Date: 04/02/2026
Certification Date: 04/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 W 72ND AVE
DENVER CO
80221-2721
US

IV. Provider business mailing address

1735 S PUBLIC RD
LAFAYETTE CO
80026-7093
US

V. Phone/Fax

Practice location:
  • Phone: 615-966-7150
  • Fax:
Mailing address:
  • Phone: 615-966-7150
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA.9056
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: