Provider Demographics
NPI:1427430032
Name:FAHRBACH, MARISSA LEE
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:LEE
Last Name:FAHRBACH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARISSSA
Other - Middle Name:LEE
Other - Last Name:BENSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:382 S ARTHUR AVE
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:CO
Mailing Address - Zip Code:80027-3094
Mailing Address - Country:US
Mailing Address - Phone:303-604-5000
Mailing Address - Fax:720-890-0364
Practice Address - Street 1:1755 48TH ST STE 100
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80301-2712
Practice Address - Country:US
Practice Address - Phone:303-604-5000
Practice Address - Fax:720-890-0364
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-19
Last Update Date:2020-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS103068163W00000X
KS557356367500000X
CO0994226367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000171761Medicaid