1285840942 NPI number — ELIZABETH ANN KUSEK PA-C

Table of content: ELIZABETH ANN KUSEK PA-C (NPI 1285840942)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285840942 NPI number — ELIZABETH ANN KUSEK PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KUSEK
Provider First Name:
ELIZABETH
Provider Middle Name:
ANN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1285840942
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1345 PLAZA COURT N.
Provider Second Line Business Mailing Address:
#1A
Provider Business Mailing Address City Name:
LAFAYETTE
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80026-2832
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
303-665-3036
Provider Business Mailing Address Fax Number:
303-604-6243

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3303 N. BROADWAY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOULDER
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80304-2241
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
303-449-6050
Provider Business Practice Location Address Fax Number:
303-604-6243
Provider Enumeration Date:
05/16/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  789 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 41483553 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".




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