Basic Information
| Provider Information | |||||||||
| NPI: | 1750399580 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | VERMILYEN | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2550 N. THUNDERBIRD CIRCLE | ||||||||
| Address2: | STE. 303 | ||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852151219 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8887058558 | ||||||||
| FaxNumber: | 4808320268 | ||||||||
| Practice Location | |||||||||
| Address1: | 4590 W 121ST AVE | ||||||||
| Address2: | |||||||||
| City: | BROOMFIELD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800205666 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3034394544 | ||||||||
| FaxNumber: | 3034399363 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/04/2006 | ||||||||
| LastUpdateDate: | 09/13/2017 | ||||||||
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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 | 363LF0000X | APN.0003609-NP | CO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 98155539 | 05 | CO | MEDICAID |