Provider Demographics
NPI:1528378817
Name:PRUSINOWSKI, LYDIA L
Entity Type:Individual
Prefix:
First Name:LYDIA
Middle Name:L
Last Name:PRUSINOWSKI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LYDIA
Other - Middle Name:
Other - Last Name:PRUSINOWSKI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 173862
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80217-3862
Mailing Address - Country:US
Mailing Address - Phone:303-306-7783
Mailing Address - Fax:303-306-7753
Practice Address - Street 1:1501 S POTOMAC ST
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80012-5411
Practice Address - Country:US
Practice Address - Phone:303-695-2628
Practice Address - Fax:303-306-7753
Is Sole Proprietor?:No
Enumeration Date:2010-10-20
Last Update Date:2015-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601005910363AM0700X
COPA.0004156363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO27507718Medicaid
CO385358YL2GMedicare PIN