Provider Demographics
NPI:1255506515
Name:PERSONS, MARY-ANNE (PA)
Entity Type:Individual
Prefix:
First Name:MARY-ANNE
Middle Name:
Last Name:PERSONS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:MARY-ANNE
Other - Middle Name:
Other - Last Name:PORTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3455 LUTHERAN PKWY STE 105
Mailing Address - Street 2:
Mailing Address - City:WHEAT RIDGE
Mailing Address - State:CO
Mailing Address - Zip Code:80033-6028
Mailing Address - Country:US
Mailing Address - Phone:303-665-2603
Mailing Address - Fax:303-665-2605
Practice Address - Street 1:1211 VIRGINIA ST
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27401-1313
Practice Address - Country:US
Practice Address - Phone:336-275-0927
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-28
Last Update Date:2024-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-10452363A00000X
CO774363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ342068Medicaid
AZZ122593Medicare PIN