Provider Demographics
NPI:1285122275
Name:NARDECCHIA, MARY ELISE (PA-C)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ELISE
Last Name:NARDECCHIA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2055 N HIGH ST STE 370
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80205-5545
Mailing Address - Country:US
Mailing Address - Phone:303-839-6001
Mailing Address - Fax:303-839-6033
Practice Address - Street 1:2055 N HIGH ST STE 370
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80205-5545
Practice Address - Country:US
Practice Address - Phone:303-839-6001
Practice Address - Fax:303-839-6033
Is Sole Proprietor?:No
Enumeration Date:2018-04-25
Last Update Date:2019-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA.0005316363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000162959Medicaid