Provider Demographics
NPI:1457546814
Name:DOUGHERTY, MICHAEL JAMES (APRN, CNS)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:JAMES
Last Name:DOUGHERTY
Suffix:
Gender:M
Credentials:APRN, CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3400 LUTHERAN PKWY
Mailing Address - Street 2:
Mailing Address - City:WHEAT RIDGE
Mailing Address - State:CO
Mailing Address - Zip Code:80033-6035
Mailing Address - Country:US
Mailing Address - Phone:303-467-4000
Mailing Address - Fax:303-467-4064
Practice Address - Street 1:3400 LUTHERAN PKWY
Practice Address - Street 2:
Practice Address - City:WHEAT RIDGE
Practice Address - State:CO
Practice Address - Zip Code:80033-6035
Practice Address - Country:US
Practice Address - Phone:303-467-4000
Practice Address - Fax:303-467-4064
Is Sole Proprietor?:No
Enumeration Date:2007-09-10
Last Update Date:2010-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COCNS-4393364SP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO07832753Medicaid
COCO300646Medicare PIN