Basic Information
| Provider Information | |||||||||
| NPI: | 1215939095 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CAIN | ||||||||
| FirstName: | MARY | ||||||||
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| Credential: | P.A.C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3853 S NELSON CT | ||||||||
| Address2: | |||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802351150 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3037955980 | ||||||||
| FaxNumber: | 3037957881 | ||||||||
| Practice Location | |||||||||
| Address1: | 7780 S BROADWAY | ||||||||
| Address2: | SUITE #150 | ||||||||
| City: | LITTLETON | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801222648 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3037955980 | ||||||||
| FaxNumber: | 3037957881 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2005 | ||||||||
| LastUpdateDate: | 09/08/2008 | ||||||||
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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 | 951 | CO | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 08103054 | 05 | CO | MEDICAID |