Provider Demographics
NPI:1629130406
Name:PACYGA, MARA DANIELLE (MSPT)
Entity Type:Individual
Prefix:
First Name:MARA
Middle Name:DANIELLE
Last Name:PACYGA
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:280 ZEREX ST
Mailing Address - Street 2:POB 1345
Mailing Address - City:FRASER
Mailing Address - State:CO
Mailing Address - Zip Code:80442-1345
Mailing Address - Country:US
Mailing Address - Phone:970-726-8503
Mailing Address - Fax:970-726-8941
Practice Address - Street 1:280 ZEREX ST.
Practice Address - Street 2:POB 1345
Practice Address - City:FRASER
Practice Address - State:CO
Practice Address - Zip Code:80442-1345
Practice Address - Country:US
Practice Address - Phone:970-726-8503
Practice Address - Fax:970-726-8941
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2008-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO76632251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO7663OtherSTATE PT LICENSE
COC810684Medicare PIN