Healthcare Provider Details

I. General information

NPI: 1801125927
Provider Name (Legal Business Name): MOUNTAIN MEDICAL CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2009
Last Update Date: 11/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

393 S HARLAN ST
LAKEWOOD CO
80226-3572
US

IV. Provider business mailing address

5534 SALVIA CT
GOLDEN CO
80403-1118
US

V. Phone/Fax

Practice location:
  • Phone: 303-596-7122
  • Fax:
Mailing address:
  • Phone: 303-596-7122
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number1354
License Number StateCO

VIII. Authorized Official

Name: NANCY ANN SMITH
Title or Position: PHYSICIAN ASSISTANT
Credential: PA-C
Phone: 303-596-7122