Healthcare Provider Details

I. General information

NPI: 1104078377
Provider Name (Legal Business Name): MARIA S RAHARDJA DNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARIA SUSANTO ANP

II. Dates (important events)

Enumeration Date: 10/18/2008
Last Update Date: 09/06/2023
Certification Date: 09/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 JACKSON ST
DENVER CO
80206-2762
US

IV. Provider business mailing address

1400 JACKSON ST
DENVER CO
80206-2762
US

V. Phone/Fax

Practice location:
  • Phone: 303-388-4461
  • Fax: 303-398-1211
Mailing address:
  • Phone: 303-388-4461
  • Fax: 303-398-1211

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberAP60015757
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: