Provider Demographics
NPI:1790818615
Name:PATRICK, LIZA DYLAN (CNM)
Entity Type:Individual
Prefix:
First Name:LIZA
Middle Name:DYLAN
Last Name:PATRICK
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1345 PLAZA COURT N.
Mailing Address - Street 2:#1A
Mailing Address - City:LAFAYETTE
Mailing Address - State:CO
Mailing Address - Zip Code:80026-2832
Mailing Address - Country:US
Mailing Address - Phone:303-665-3036
Mailing Address - Fax:303-604-6243
Practice Address - Street 1:3303 N. BROADWAY ST.
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80304-2241
Practice Address - Country:US
Practice Address - Phone:303-449-6050
Practice Address - Fax:303-604-6243
Is Sole Proprietor?:No
Enumeration Date:2007-03-13
Last Update Date:2008-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO123793367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO49424882Medicaid