Provider Demographics
NPI:1255981122
Name:CARRASCO, MARY JEAL (NURSE PRACTITIONER)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:JEAL
Last Name:CARRASCO
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3441 E 13TH AVE
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80206-2608
Mailing Address - Country:US
Mailing Address - Phone:720-941-4116
Mailing Address - Fax:
Practice Address - Street 1:6850 E EVANS AVE STE 102
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80224-2300
Practice Address - Country:US
Practice Address - Phone:303-691-5009
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-12
Last Update Date:2020-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3747A0650X
CO0995405-NP363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No3747A0650XNursing Service Related ProvidersTechnicianAttendant Care ProviderGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CONONEOtherN/A