Provider Demographics
NPI:1710961206
Name:PECORARO, SUZANNE Y
Entity Type:Individual
Prefix:
First Name:SUZANNE
Middle Name:Y
Last Name:PECORARO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:345 MAXWELL AVE
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80304-3972
Mailing Address - Country:US
Mailing Address - Phone:303-544-5777
Mailing Address - Fax:303-544-5775
Practice Address - Street 1:1155 ALPINE AVE
Practice Address - Street 2:STE 260
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80304-3495
Practice Address - Country:US
Practice Address - Phone:303-444-4441
Practice Address - Fax:303-444-2015
Is Sole Proprietor?:No
Enumeration Date:2005-11-30
Last Update Date:2008-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COR344988133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
COQ06675Medicare UPIN
CO522788Medicare ID - Type Unspecified
COC522788Medicare PIN