Provider Demographics
NPI:1316286008
Name:FUENMAYOR, CARLOS EDUARDO (CSA)
Entity type:Individual
Prefix:
First Name:CARLOS
Middle Name:EDUARDO
Last Name:FUENMAYOR
Suffix:
Gender:M
Credentials:CSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22154 E EUCLID DR
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80016-2359
Mailing Address - Country:US
Mailing Address - Phone:720-377-4160
Mailing Address - Fax:
Practice Address - Street 1:1673 S FLANDERS WAY
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80017-5509
Practice Address - Country:US
Practice Address - Phone:720-748-2888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-31
Last Update Date:2013-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO13-115363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical