Basic Information
| Provider Information | |||||||||
| NPI: | 1184393654 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MAREK | ||||||||
| FirstName: | VLASTISLAV | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | III | ||||||||
| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2109 PEACEMAKER TER W | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809203815 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7193515288 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 6915 TUTT BOULEVARD | ||||||||
| Address2: | SUITE #110B | ||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 80923 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7194451292 | ||||||||
| FaxNumber: | 7195916486 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/08/2021 | ||||||||
| LastUpdateDate: | 03/07/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN1631454 | CO | N | Nursing Service Providers | Registered Nurse | 363LF0000X | RXN.0106234-NP | CO | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | APN.0997172-NP | CO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.