Basic Information
| Provider Information | |||||||||
| NPI: | 1386640373 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KSIAZEK | ||||||||
| FirstName: | KAREN | ||||||||
| MiddleName: | LEE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KSIAZEK-WILSON | ||||||||
| OtherFirstName: | KAREN | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 8333 RALSTON RD STE 1 | ||||||||
| Address2: | |||||||||
| City: | ARVADA | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800022355 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7202958127 | ||||||||
| FaxNumber: | 3034231062 | ||||||||
| Practice Location | |||||||||
| Address1: | 1687 COLE BLVD STE 103 | ||||||||
| Address2: | |||||||||
| City: | LAKEWOOD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 804013318 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3034036688 | ||||||||
| FaxNumber: | 3034036245 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2005 | ||||||||
| LastUpdateDate: | 08/29/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/29/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | 30621 | CO | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 01306216 | 05 | CO | MEDICAID |