Provider Demographics
NPI:1285173203
Name:IBRAHIM, NATALIE MANNON (PA-C)
Entity type:Individual
Prefix:
First Name:NATALIE
Middle Name:MANNON
Last Name:IBRAHIM
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:NATALIE
Other - Middle Name:MARIE
Other - Last Name:MANNON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:777 29TH ST STE 301
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80303-2316
Mailing Address - Country:US
Mailing Address - Phone:303-440-8243
Mailing Address - Fax:303-440-0292
Practice Address - Street 1:777 29TH ST STE 301
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80303-2316
Practice Address - Country:US
Practice Address - Phone:303-440-8243
Practice Address - Fax:303-440-0292
Is Sole Proprietor?:No
Enumeration Date:2017-02-23
Last Update Date:2023-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0004763363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant