Healthcare Provider Details

I. General information

NPI: 1003492364
Provider Name (Legal Business Name): NATALIE LUCILLE TANNENBAUM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/18/2021
Last Update Date: 04/18/2023
Certification Date: 04/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3501 S CLARKSON ST
ENGLEWOOD CO
80113-3916
US

IV. Provider business mailing address

15455 CANYON RIM DR UNIT 207
ENGLEWOOD CO
80112-4731
US

V. Phone/Fax

Practice location:
  • Phone: 303-783-8844
  • Fax:
Mailing address:
  • Phone: 303-726-2364
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA.0006741
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: