Provider Demographics
NPI:1023852720
Name:STELLAR GENESIS PROFESSIONAL LLC
Entity type:Organization
Organization Name:STELLAR GENESIS PROFESSIONAL LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:YUKO
Authorized Official - Middle Name:
Authorized Official - Last Name:BLUE
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:303-582-4657
Mailing Address - Street 1:2012 S BRYANT ST
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80219-5524
Mailing Address - Country:US
Mailing Address - Phone:303-582-4657
Mailing Address - Fax:
Practice Address - Street 1:2806 NORTH SPEEK BLVD
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80211
Practice Address - Country:US
Practice Address - Phone:303-582-4657
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-06-19
Last Update Date:2024-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty