Provider Demographics
NPI:1184078180
Name:ABERNATHY, MACK
Entity type:Individual
Prefix:MS
First Name:MACK
Middle Name:
Last Name:ABERNATHY
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 1:11059 E BETHANY DR STE 200
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80014-2637
Mailing Address - Country:US
Mailing Address - Phone:303-617-2300
Mailing Address - Fax:303-617-2397
Practice Address - Street 1:11059 E BETHANY DR STE 200
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80014-2637
Practice Address - Country:US
Practice Address - Phone:303-617-2300
Practice Address - Fax:303-617-2397
Is Sole Proprietor?:No
Enumeration Date:2016-04-16
Last Update Date:2016-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
COO97820701Medicaid