Provider Demographics
NPI:1568421808
Name:REDAR, CAROLYN R (PA)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:R
Last Name:REDAR
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8580 SCARBOROUGH DR STE 225
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80920-7586
Mailing Address - Country:US
Mailing Address - Phone:719-531-5400
Mailing Address - Fax:
Practice Address - Street 1:8580 SCARBOROUGH DR STE 225
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80920-7586
Practice Address - Country:US
Practice Address - Phone:719-531-5400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2020-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA.0006372363A00000X
IN10001619A363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIN96800001Medicare PIN
MIH06995Medicare UPIN