Provider Demographics
NPI:1366500779
Name:BYRON, MARY JOSEPHINE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:JOSEPHINE
Last Name:BYRON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:MARY
Other - Middle Name:JOSEPHINE
Other - Last Name:SANTOS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:5450 WESTERN AVE STE B
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80301-2709
Mailing Address - Country:US
Mailing Address - Phone:303-442-2395
Mailing Address - Fax:303-442-1073
Practice Address - Street 1:525 N FOOTE AVE
Practice Address - Street 2:STE 302
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909-4501
Practice Address - Country:US
Practice Address - Phone:719-365-5445
Practice Address - Fax:719-365-5530
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2017-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA-3218363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO83304371Medicaid
COCOA109601Medicare PIN
CO273445YL5BMedicare PIN
CO83304371Medicaid