1437232949 NPI number — MARY ELIZABETH STULTS P.A.-C

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1437232949 NPI number — MARY ELIZABETH STULTS P.A.-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STULTS
Provider First Name:
MARY
Provider Middle Name:
ELIZABETH
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
P.A.-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HISATOMI
Provider Other First Name:
MARY
Provider Other Middle Name:
ELIZABETH
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1437232949
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/30/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
198 UNION BLVD
Provider Second Line Business Mailing Address:
SUITE 150
Provider Business Mailing Address City Name:
LAKEWOOD
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80228-2259
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
303-892-6033
Provider Business Mailing Address Fax Number:
303-573-6929

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
198 UNION BLVD
Provider Second Line Business Practice Location Address:
SUITE 150
Provider Business Practice Location Address City Name:
LAKEWOOD
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80228-2259
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
303-892-6033
Provider Business Practice Location Address Fax Number:
303-573-6929
Provider Enumeration Date:
10/20/2006

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: 363AM0700X , with the licence number:  3345 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363AM0700X , with the licence number: C000333 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 92878563 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".




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