Basic Information
| Provider Information | |||||||||
| NPI: | 1861895807 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | TANABE | ||||||||
| FirstName: | TERESA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4100 E MISSISSIPPI AVE | ||||||||
| Address2: | STE 110 | ||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802463051 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3038694664 | ||||||||
| FaxNumber: | 3039961600 | ||||||||
| Practice Location | |||||||||
| Address1: | 3551 CHAMBERS RD # A-D | ||||||||
| Address2: | |||||||||
| City: | AURORA | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800111330 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3033750649 | ||||||||
| FaxNumber: | 3033750986 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2014 | ||||||||
| LastUpdateDate: | 03/16/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 991480 | CO | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LP2300X | 95000952 | CA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care | 363LP2300X | APN.0991480-NP | CO | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care | 363LG0600X | APN.0991480-NP | CO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology |
ID Information
| ID | Type | State | Issuer | Description | 07786751 | 05 | CO | MEDICAID |