Provider Demographics
NPI:1770727471
Name:PEARSON, WILLIAM J
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:J
Last Name:PEARSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:264 CRADLE LAKE DR
Mailing Address - Street 2:
Mailing Address - City:DIVIDE
Mailing Address - State:CO
Mailing Address - Zip Code:80814-9780
Mailing Address - Country:US
Mailing Address - Phone:719-687-3412
Mailing Address - Fax:
Practice Address - Street 1:264 CRADLE LAKE DR
Practice Address - Street 2:
Practice Address - City:DIVIDE
Practice Address - State:CO
Practice Address - Zip Code:80814-9780
Practice Address - Country:US
Practice Address - Phone:719-687-3412
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-24
Last Update Date:2009-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171WH0202XOther Service ProvidersContractorHome Modifications
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO33188564Medicaid