1528024577 NPI number — MRS. TARA LYNN EWALD PT

Table of content: MRS. TARA LYNN EWALD PT (NPI 1528024577)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528024577 NPI number — MRS. TARA LYNN EWALD PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EWALD
Provider First Name:
TARA
Provider Middle Name:
LYNN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PT
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:
1528024577
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/20/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2343 ELKHORN STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PARKER
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80138
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
720-870-4290
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
15201 E MONCRIEFF PL
Provider Second Line Business Practice Location Address:
SUITE G
Provider Business Practice Location Address City Name:
AURORA
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80011-1261
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
720-374-8522
Provider Business Practice Location Address Fax Number:
720-374-8533
Provider Enumeration Date:
04/26/2006

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: 225100000X , with the licence number:  7333 , 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)





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