Provider Demographics
NPI:1619286424
Name:ROSENBLUM, AMY WYATT (PA-C)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:WYATT
Last Name:ROSENBLUM
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:LYNN
Other - Last Name:WYATT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 173362
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80217-3362
Mailing Address - Country:US
Mailing Address - Phone:303-615-9999
Mailing Address - Fax:720-778-5850
Practice Address - Street 1:955 LAWRENCE WAY
Practice Address - Street 2:SUITE 150
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80204
Practice Address - Country:US
Practice Address - Phone:303-615-9999
Practice Address - Fax:720-778-5850
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-28
Last Update Date:2025-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VADT07529133V00000X
VA363AM0700X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1619286424Medicaid
VAVVS807AOtherMEDICARE