1770929754 NPI number — CARSON ELIZABETH PETTY MAYNARD DO

Table of content: CARSON ELIZABETH PETTY MAYNARD DO (NPI 1770929754)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770929754 NPI number — CARSON ELIZABETH PETTY MAYNARD DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MAYNARD
Provider First Name:
CARSON
Provider Middle Name:
ELIZABETH PETTY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
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:
1770929754
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/14/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1715 IRON HORSE DR
Provider Second Line Business Mailing Address:
STE 100
Provider Business Mailing Address City Name:
LONGMONT
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80501-9617
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
720-494-4700
Provider Business Mailing Address Fax Number:
720-494-4706

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3455 LUTHERAN PKWY STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WHEAT RIDGE
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80033-6028
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
720-494-4700
Provider Business Practice Location Address Fax Number:
720-494-4706
Provider Enumeration Date:
05/16/2013

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: 207R00000X , with the licence number:  60242 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RR0500X , with the licence number: 60242 , 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)