Provider Demographics
NPI:1932211174
Name:CEAZAN, MARNIE (PA)
Entity Type:Individual
Prefix:MS
First Name:MARNIE
Middle Name:
Last Name:CEAZAN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1430 JUDSON DR
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80305-6933
Mailing Address - Country:US
Mailing Address - Phone:303-499-8182
Mailing Address - Fax:
Practice Address - Street 1:1420 W MIDWAY BLVD
Practice Address - Street 2:
Practice Address - City:BROOMFIELD
Practice Address - State:CO
Practice Address - Zip Code:80020-2090
Practice Address - Country:US
Practice Address - Phone:303-466-1886
Practice Address - Fax:303-466-4081
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO00733363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO512968Medicare ID - Type Unspecified
COQ00132Medicare UPIN