Provider Demographics
NPI:1437232949
Name:STULTS, MARY ELIZABETH (PA-C)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ELIZABETH
Last Name:STULTS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:ELIZABETH
Other - Last Name:HISATOMI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:198 UNION BLVD
Mailing Address - Street 2:SUITE 150
Mailing Address - City:LAKEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80228-2259
Mailing Address - Country:US
Mailing Address - Phone:303-892-6033
Mailing Address - Fax:303-573-6929
Practice Address - Street 1:198 UNION BLVD
Practice Address - Street 2:SUITE 150
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80228-2259
Practice Address - Country:US
Practice Address - Phone:303-892-6033
Practice Address - Fax:303-573-6929
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO3345363AM0700X
MDC000333363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO92878563Medicaid
DC020454S14Medicare PIN
CO262651Medicare PIN