Provider Demographics
NPI:1639232549
Name:BAKKEN, LIZA N (PT)
Entity Type:Individual
Prefix:
First Name:LIZA
Middle Name:N
Last Name:BAKKEN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:LIZA
Other - Middle Name:
Other - Last Name:WENACUR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:STE A
Mailing Address - Street 2:303 ASPEN BUSINESS CTR
Mailing Address - City:ASPEN
Mailing Address - State:CO
Mailing Address - Zip Code:81611-3500
Mailing Address - Country:US
Mailing Address - Phone:970-920-1070
Mailing Address - Fax:
Practice Address - Street 1:STE A
Practice Address - Street 2:303 ASPEN BUSINESS CTR
Practice Address - City:ASPEN
Practice Address - State:CO
Practice Address - Zip Code:81611-3500
Practice Address - Country:US
Practice Address - Phone:970-920-1070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2008-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO6862225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
COC807531Medicare PIN
CO447168Medicare UPIN