Basic Information
| Provider Information | |||||||||
| NPI: | 1679558365 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LAURNEN | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | M D | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 150 | ||||||||
| Address2: | |||||||||
| City: | HOLLY | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810470150 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195370712 | ||||||||
| FaxNumber: | 7195376284 | ||||||||
| Practice Location | |||||||||
| Address1: | 660 GOLDEN RIDGE RD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | GOLDEN | ||||||||
| State: | CO | ||||||||
| PostalCode: | 804019541 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3039631505 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/14/2005 | ||||||||
| LastUpdateDate: | 04/27/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 29825 | CO | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 01298256 | 05 | CO | MEDICAID |