Provider Demographics
NPI:1720244619
Name:NICODEMUS, MALENA MICHELLE (PA)
Entity Type:Individual
Prefix:
First Name:MALENA
Middle Name:MICHELLE
Last Name:NICODEMUS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:MALENA
Other - Middle Name:MICHELLE
Other - Last Name:DOEHLING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:2400 S PEORIA ST
Mailing Address - Street 2:#100
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80014-5476
Mailing Address - Country:US
Mailing Address - Phone:303-306-4321
Mailing Address - Fax:303-306-4347
Practice Address - Street 1:2400 S PEORIA ST
Practice Address - Street 2:#100
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80014-5476
Practice Address - Country:US
Practice Address - Phone:303-306-4321
Practice Address - Fax:303-306-4347
Is Sole Proprietor?:No
Enumeration Date:2008-07-31
Last Update Date:2012-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2618363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO91423287Medicaid
CO91423287Medicaid