Basic Information
| Provider Information | |||||||||
| NPI: | 1790183416 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MAYEUX | ||||||||
| FirstName: | JACK | ||||||||
| MiddleName: | J. | ||||||||
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| Credential: | APRN, FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 529 | ||||||||
| Address2: | |||||||||
| City: | OLATHE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 814250529 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9703236141 | ||||||||
| FaxNumber: | 8552998071 | ||||||||
| Practice Location | |||||||||
| Address1: | 1010 S RIO GRANDE AVE | ||||||||
| Address2: | |||||||||
| City: | MONTROSE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 814014831 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9703236141 | ||||||||
| FaxNumber: | 8552998071 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/11/2014 | ||||||||
| LastUpdateDate: | 05/17/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/17/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | AP08146 | LA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | C-APN.0003532-C-APN | CO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.