Provider Demographics
NPI:1215939095
Name:CAIN, MARY (PAC)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:CAIN
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3853 S NELSON CT
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80235-1150
Mailing Address - Country:US
Mailing Address - Phone:303-795-5980
Mailing Address - Fax:303-795-7881
Practice Address - Street 1:7780 S BROADWAY
Practice Address - Street 2:SUITE #150
Practice Address - City:LITTLETON
Practice Address - State:CO
Practice Address - Zip Code:80122-2648
Practice Address - Country:US
Practice Address - Phone:303-795-5980
Practice Address - Fax:303-795-7881
Is Sole Proprietor?:No
Enumeration Date:2005-08-11
Last Update Date:2008-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO951363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO08103054Medicaid
CO08103054Medicaid