Provider Demographics
NPI:1073074290
Name:RASMUSSEN, MARY ANNELISE
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ANNELISE
Last Name:RASMUSSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12631 E 17TH AVE
Mailing Address - Street 2:MAIL STOP F493,AO1, RM 1201E
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80045-2527
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:PM&R RESIDENCY PROGRAM
Practice Address - Street 2:12631 E 17TH AVE
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80045
Practice Address - Country:US
Practice Address - Phone:720-848-1980
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-29
Last Update Date:2022-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
COTL.0009144390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program