Provider Demographics
NPI:1235287541
Name:VANWYK, JILL R (MD)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:R
Last Name:VANWYK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80305-3343
Mailing Address - Country:US
Mailing Address - Phone:720-848-9200
Mailing Address - Fax:
Practice Address - Street 1:5495 ARAPAHOE AVE
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80303-1260
Practice Address - Country:US
Practice Address - Phone:720-848-9200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-05
Last Update Date:2017-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR0052110207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8437485Medicaid
WA8437485Medicaid
WAG8856483Medicare PIN