Provider Demographics
NPI:1477012094
Name:BRIZUELA MORAN, WILMER DEL CARMEN (SA-C)
Entity Type:Individual
Prefix:
First Name:WILMER
Middle Name:DEL CARMEN
Last Name:BRIZUELA MORAN
Suffix:
Gender:M
Credentials:SA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1755 S BEELER ST UNIT 11D
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80247-2913
Mailing Address - Country:US
Mailing Address - Phone:424-351-5593
Mailing Address - Fax:
Practice Address - Street 1:1755 S BEELER ST UNIT 11D
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80247-2913
Practice Address - Country:US
Practice Address - Phone:424-351-5593
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-13
Last Update Date:2019-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO16-441246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant