Basic Information
| Provider Information | |||||||||
| NPI: | 1306334263 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETRASH | ||||||||
| FirstName: | CIARA | ||||||||
| MiddleName: | RAYNE | ||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MCKENZIE | ||||||||
| OtherFirstName: | CIARA | ||||||||
| OtherMiddleName: | RAYNE | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 16111 OLD FOREST PT APT 100 | ||||||||
| Address2: | |||||||||
| City: | MONUMENT | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801328675 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | |||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 6189 LEHMAN DR STE 202 | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809185409 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7192661000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2018 | ||||||||
| LastUpdateDate: | 10/14/2018 | ||||||||
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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 | 106S00000X | Y |
No ID Information.