Provider Demographics
NPI:1154458198
Name:HOLSCLAW, SUSAN L
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:L
Last Name:HOLSCLAW
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 1:280 EXEMPLA CIR
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:CO
Mailing Address - Zip Code:80026-3370
Mailing Address - Country:US
Mailing Address - Phone:720-536-7934
Mailing Address - Fax:
Practice Address - Street 1:280 EXEMPLA CIR
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:CO
Practice Address - Zip Code:80026-3370
Practice Address - Country:US
Practice Address - Phone:720-536-7934
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2007-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO16270208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
013478OtherKAISER-COMMERCIAL NUMBER
COC1154458198Medicare PIN