Provider Demographics
NPI:1619245867
Name:BADER, JOANNE WILSON (PA)
Entity Type:Individual
Prefix:
First Name:JOANNE
Middle Name:WILSON
Last Name:BADER
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 1:1360 S POTOMAC ST
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80012-4505
Mailing Address - Country:US
Mailing Address - Phone:303-337-5575
Mailing Address - Fax:303-745-6264
Practice Address - Street 1:1360 S POTOMAC ST
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80012
Practice Address - Country:US
Practice Address - Phone:303-337-5575
Practice Address - Fax:303-745-6264
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-02
Last Update Date:2011-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO403363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant