Provider Demographics
NPI:1104078377
Name:RAHARDJA, MARIA S (DNP)
Entity type:Individual
Prefix:
First Name:MARIA
Middle Name:S
Last Name:RAHARDJA
Suffix:
Gender:F
Credentials:DNP
Other - Prefix:
Other - First Name:MARIA
Other - Middle Name:
Other - Last Name:SUSANTO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ANP
Mailing Address - Street 1:1400 JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80206-2762
Mailing Address - Country:US
Mailing Address - Phone:303-388-4461
Mailing Address - Fax:303-398-1211
Practice Address - Street 1:1400 JACKSON ST
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80206-2762
Practice Address - Country:US
Practice Address - Phone:303-388-4461
Practice Address - Fax:303-398-1211
Is Sole Proprietor?:No
Enumeration Date:2008-10-18
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP60015757363LA2200X
CORN.1683247363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health