Provider Demographics
NPI:1497341051
Name:BUKASA, CARLOS
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:
Last Name:BUKASA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2267 S GIBRALTER WAY
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80013-6275
Mailing Address - Country:US
Mailing Address - Phone:720-532-3626
Mailing Address - Fax:
Practice Address - Street 1:2267 S GIBRALTER WAY
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80013-6275
Practice Address - Country:US
Practice Address - Phone:720-532-3626
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-17
Last Update Date:2020-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO09-155-0444Medicaid