Healthcare Provider Details

I. General information

NPI: 1740290659
Provider Name (Legal Business Name): TAMARA LYNNE WRISTEN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2006
Last Update Date: 11/21/2023
Certification Date: 11/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1202 5TH ST PLAZA BUILDING, SUITE 150
DENVER CO
80204-2006
US

IV. Provider business mailing address

PO BOX 173362 CAMPUS BOX 20
DENVER CO
80217-3362
US

V. Phone/Fax

Practice location:
  • Phone: 303-556-2525
  • Fax: 303-556-3881
Mailing address:
  • Phone: 303-615-9999
  • Fax: 720-778-5850

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number632
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: