Basic Information
| Provider Information | |||||||||
| NPI: | 1134103286 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRIFFITH | ||||||||
| FirstName: | SUE | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5450 WESTERN AVE | ||||||||
| Address2: | |||||||||
| City: | BOULDER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 803012709 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3034157450 | ||||||||
| FaxNumber: | 3034945265 | ||||||||
| Practice Location | |||||||||
| Address1: | 1755 48TH ST | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | BOULDER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 803012711 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3034157450 | ||||||||
| FaxNumber: | 3034945265 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/02/2005 | ||||||||
| LastUpdateDate: | 11/09/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA.0000459 | CO | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 970021431 | 01 | CO | MEDICARE RAILROAD | OTHER | 34189769 | 05 | CO | MEDICAID |