Provider Demographics
NPI:1285850628
Name:VAN DER MERSCH, MARTHA S (RNC)
Entity Type:Individual
Prefix:MS
First Name:MARTHA
Middle Name:S
Last Name:VAN DER MERSCH
Suffix:
Gender:F
Credentials:RNC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:840 QUINCE AVE
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80304-0746
Mailing Address - Country:US
Mailing Address - Phone:303-444-0670
Mailing Address - Fax:
Practice Address - Street 1:2855 VALMONT RD
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80301-1309
Practice Address - Country:US
Practice Address - Phone:303-442-5160
Practice Address - Fax:303-440-8769
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO64281363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO07642812Medicaid