Basic Information
Provider Information | |||||||||
NPI: | 1720244619 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | NICODEMUS | ||||||||
FirstName: | MALENA | ||||||||
MiddleName: | MICHELLE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | DOEHLING | ||||||||
OtherFirstName: | MALENA | ||||||||
OtherMiddleName: | MICHELLE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PA | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 2400 S PEORIA ST | ||||||||
Address2: | #100 | ||||||||
City: | AURORA | ||||||||
State: | CO | ||||||||
PostalCode: | 800145476 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3033064321 | ||||||||
FaxNumber: | 3033064347 | ||||||||
Practice Location | |||||||||
Address1: | 2400 S PEORIA ST | ||||||||
Address2: | #100 | ||||||||
City: | AURORA | ||||||||
State: | CO | ||||||||
PostalCode: | 800145476 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3033064321 | ||||||||
FaxNumber: | 3033064347 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/31/2008 | ||||||||
LastUpdateDate: | 09/09/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 2618 | CO | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
ID Information
ID | Type | State | Issuer | Description | 91423287 | 05 | CO |   | MEDICAID |