1083675995 NPI number — ANDREA L GRACE P.A.

Table of content: ALYSSA JOLEE O'SHEA (NPI 1669278529)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083675995 NPI number — ANDREA L GRACE P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRACE
Provider First Name:
ANDREA
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
P.A.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BACA
Provider Other First Name:
ANDREA
Provider Other Middle Name:
L
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1083675995
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/14/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4900 S. MONACO ST
Provider Second Line Business Mailing Address:
#210
Provider Business Mailing Address City Name:
DENVER
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80237-3486
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
720-754-4800
Provider Business Mailing Address Fax Number:
720-754-4801

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1721 E 19TH AVE STE 300
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DENVER
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80218-1258
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
720-754-4800
Provider Business Practice Location Address Fax Number:
720-754-4801
Provider Enumeration Date:
03/30/2006

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: 363AS0400X , with the licence number:  2260 , 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: 85289221 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".
  • Identifier: COAAA1569 . This is a "MEDICARE" identifier , issued by the state of ( CO ) . This identifiers is of the category "OTHER".




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