Provider Demographics
NPI:1912550989
Name:IM, CAROLYN S
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:S
Last Name:IM
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 1:3501 S CLARKSON ST
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80113-3916
Mailing Address - Country:US
Mailing Address - Phone:303-783-8844
Mailing Address - Fax:303-783-2002
Practice Address - Street 1:3501 S CLARKSON ST
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80113-3916
Practice Address - Country:US
Practice Address - Phone:303-783-8844
Practice Address - Fax:303-783-2002
Is Sole Proprietor?:No
Enumeration Date:2019-07-19
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA.0006728363A00000X, 363AM0700X
363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100096114Medicaid