Healthcare Provider Details

I. General information

NPI: 1194202218
Provider Name (Legal Business Name): DENNISE ESTEFANIA SALAZAR PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2018
Last Update Date: 08/21/2024
Certification Date: 08/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

736 ROUTE 4 STE 103
SINAJANA GU
96910-3368
US

IV. Provider business mailing address

736 ROUTE 4 STE 103
SINAJANA GU
96910-3368
US

V. Phone/Fax

Practice location:
  • Phone: 671-649-7232
  • Fax: 671-649-7233
Mailing address:
  • Phone: 671-649-7232
  • Fax: 671-649-7233

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number6011
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA-147
License Number StateGU

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: