Provider Demographics
NPI:1942331582
Name:SCOTT, MARY RYAN (APN)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:RYAN
Last Name:SCOTT
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2820 TABLE MESA DR
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80305-5749
Mailing Address - Country:US
Mailing Address - Phone:505-670-5050
Mailing Address - Fax:
Practice Address - Street 1:3 SUPERIOR DR STE 100B
Practice Address - Street 2:
Practice Address - City:SUPERIOR
Practice Address - State:CO
Practice Address - Zip Code:80027-8653
Practice Address - Country:US
Practice Address - Phone:303-415-8940
Practice Address - Fax:303-425-9259
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-07
Last Update Date:2022-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMR33217363LF0000X
CO3912363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM00077947Medicaid
NM00077947Medicaid