Provider Demographics
NPI:1578602496
Name:LAUDERMILK, MARK R (PA)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:R
Last Name:LAUDERMILK
Suffix:
Gender:M
Credentials:PA
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Mailing Address - Street 1:10800 E GEDDES AVE STE 300
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80112-3895
Mailing Address - Country:US
Mailing Address - Phone:303-761-9190
Mailing Address - Fax:720-874-4462
Practice Address - Street 1:2525 S DOWNING ST
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80210-5817
Practice Address - Country:US
Practice Address - Phone:303-761-9190
Practice Address - Fax:720-874-4462
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2024-03-29
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CO2356363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200425750AMedicaid
CO73656038Medicaid
WY1578602496Medicaid
NM87528771Medicaid
NM87528771Medicaid
COC807551Medicare PIN