Provider Demographics
NPI:1487804852
Name:RAE, NICOLE R (PAC)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:R
Last Name:RAE
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 1:125 RAMPART WAY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80230-6406
Mailing Address - Country:US
Mailing Address - Phone:720-858-7434
Mailing Address - Fax:720-858-7605
Practice Address - Street 1:125 RAMPART WAY
Practice Address - Street 2:SUITE 200
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80230-6406
Practice Address - Country:US
Practice Address - Phone:720-858-7434
Practice Address - Fax:720-858-7605
Is Sole Proprietor?:No
Enumeration Date:2008-09-23
Last Update Date:2009-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1171174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
1487804852OtherNPI
CO301905Medicare PIN