Provider Demographics
NPI:1720654478
Name:CONYERS, MARIAH (PA-C)
Entity Type:Individual
Prefix:
First Name:MARIAH
Middle Name:
Last Name:CONYERS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:565 REMINGTON DR
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:CO
Mailing Address - Zip Code:80642-7408
Mailing Address - Country:US
Mailing Address - Phone:402-910-1019
Mailing Address - Fax:
Practice Address - Street 1:565 REMINGTON DR
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:CO
Practice Address - Zip Code:80642-7408
Practice Address - Country:US
Practice Address - Phone:402-910-1019
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-02
Last Update Date:2022-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10003772A363A00000X
363A00000X
IL085008522363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant