Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LP0200X | Nurse Practitioner - Pediatrics | 128803 | CO |
NPI | 1043395783 |
---|---|
Provider Name | Mary Maddox |
First Address | Aurora, CO 80042-0429 |
Second Address | Aurora, CO 80045-7106 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 25/10/2006 |
Last Update Date | 26/10/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
66100577 | (05) | CO |