Provider Demographics
NPI:1588107098
Name:GRADISAR, DAMIAN (ACNP)
Entity type:Individual
Prefix:
First Name:DAMIAN
Middle Name:
Last Name:GRADISAR
Suffix:
Gender:M
Credentials:ACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1919 W US HIGHWAY 50
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81008-1618
Mailing Address - Country:US
Mailing Address - Phone:719-253-7102
Mailing Address - Fax:719-253-7114
Practice Address - Street 1:1919 W US HIGHWAY 50
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81008-1618
Practice Address - Country:US
Practice Address - Phone:719-253-7102
Practice Address - Fax:719-253-7114
Is Sole Proprietor?:No
Enumeration Date:2016-12-01
Last Update Date:2017-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COAPN0992783NP363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO548353YTH8Medicare UPIN