Provider Demographics
NPI:1760434575
Name:BEDOSKY, MARY LOUISE (PA-C)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:LOUISE
Last Name:BEDOSKY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2930 11TH AVE
Mailing Address - Street 2:
Mailing Address - City:EVANS
Mailing Address - State:CO
Mailing Address - Zip Code:80620-1011
Mailing Address - Country:US
Mailing Address - Phone:970-350-4602
Mailing Address - Fax:970-350-4692
Practice Address - Street 1:302 3RD ST SE STE 150
Practice Address - Street 2:
Practice Address - City:LOVELAND
Practice Address - State:CO
Practice Address - Zip Code:80537-6419
Practice Address - Country:US
Practice Address - Phone:970-669-4855
Practice Address - Fax:970-669-7389
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2024-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3256363AM0700X
CO4369363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZQ56095Medicare UPIN
Z144648Medicare PIN
AZZ106488Medicare PIN