Basic Information
Provider Information | |||||||||
NPI: | 1093839730 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MARINELLO | ||||||||
FirstName: | LAURA | ||||||||
MiddleName: | S | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 51 WEST 84TH AVE | ||||||||
Address2: | SUITE 210 | ||||||||
City: | DENVER | ||||||||
State: | CO | ||||||||
PostalCode: | 802604882 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3034271601 | ||||||||
FaxNumber: | 3034266412 | ||||||||
Practice Location | |||||||||
Address1: | 1800 15TH ST | ||||||||
Address2: | SUITE 310 | ||||||||
City: | GREELEY | ||||||||
State: | CO | ||||||||
PostalCode: | 806314500 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9703920900 | ||||||||
FaxNumber: | 9705063796 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/19/2007 | ||||||||
LastUpdateDate: | 06/29/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 2206 | CO | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
ID Information
ID | Type | State | Issuer | Description | MM1400554 | 01 | CO | DEA | OTHER |