Provider Demographics
NPI:1326012618
Name:SWAN, STEPHEN M
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:M
Last Name:SWAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:STEPHEN
Other - Middle Name:M
Other - Last Name:SWAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 173894
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80217-3894
Mailing Address - Country:US
Mailing Address - Phone:303-306-7783
Mailing Address - Fax:303-306-7753
Practice Address - Street 1:1100 BALSAM AVE
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80304-3404
Practice Address - Country:US
Practice Address - Phone:303-440-2037
Practice Address - Fax:303-306-7753
Is Sole Proprietor?:No
Enumeration Date:2006-02-14
Last Update Date:2015-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPAL 1917207P00000X
COPA.0001917363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO7555344Medicaid
CO423760YUQWMedicare PIN
COQ10664Medicare UPIN
CO7555344Medicaid