Provider Demographics
NPI:1558498576
Name:WIEDERRICH, PAMELA R
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:R
Last Name:WIEDERRICH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13511 SHOSHONE ST
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:CO
Mailing Address - Zip Code:80234-1043
Mailing Address - Country:US
Mailing Address - Phone:303-667-2400
Mailing Address - Fax:
Practice Address - Street 1:11245 HURON ST
Practice Address - Street 2:
Practice Address - City:WESTMINSTER
Practice Address - State:CO
Practice Address - Zip Code:80234-2806
Practice Address - Country:US
Practice Address - Phone:303-743-5855
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2008-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO111280163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
014428OtherKAISER-COMMERCIAL NUMBER