Healthcare Provider Details

I. General information

NPI: 1811400849
Provider Name (Legal Business Name): DANIEL MIRSHAMSI APN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/13/2017
Last Update Date: 12/21/2022
Certification Date: 12/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 W 24TH ST
PUEBLO CO
81003-1411
US

IV. Provider business mailing address

1600 W 24TH ST
PUEBLO CO
81003-1411
US

V. Phone/Fax

Practice location:
  • Phone: 719-546-4312
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberAPN.0993531-NP
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPN.0993531-NP
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: