Healthcare Provider Details

I. General information

NPI: 1588856116
Provider Name (Legal Business Name): LARS VANETTEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: DR. LARS VAN ETTEN

II. Dates (important events)

Enumeration Date: 08/17/2007
Last Update Date: 11/10/2022
Certification Date: 11/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9 JUDYS DREAM LN
PUEBLO CO
81005-8703
US

IV. Provider business mailing address

9 JUDYS DREAM LN
PUEBLO CO
81005-8703
US

V. Phone/Fax

Practice location:
  • Phone: 719-242-5811
  • Fax: 719-212-2009
Mailing address:
  • Phone: 719-242-5811
  • Fax: 719-212-2009

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number46518
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number46518
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: