Healthcare Provider Details

I. General information

NPI: 1760434575
Provider Name (Legal Business Name): MARY LOUISE BEDOSKY PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2006
Last Update Date: 02/09/2024
Certification Date: 02/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

302 3RD ST SE STE 150
LOVELAND CO
80537-6419
US

IV. Provider business mailing address

2930 11TH AVE
EVANS CO
80620-1011
US

V. Phone/Fax

Practice location:
  • Phone: 970-669-4855
  • Fax: 970-669-7389
Mailing address:
  • Phone: 970-350-4602
  • Fax: 970-350-4692

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number3256
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number4369
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: