Provider Demographics
NPI:1932256773
Name:MULDOON, BRONWYN K (RPT)
Entity Type:Individual
Prefix:MRS
First Name:BRONWYN
Middle Name:K
Last Name:MULDOON
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:349 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LYONS
Mailing Address - State:CO
Mailing Address - Zip Code:80540-1960
Mailing Address - Country:US
Mailing Address - Phone:303-823-8813
Mailing Address - Fax:303-823-2355
Practice Address - Street 1:442 HIGH ST
Practice Address - Street 2:
Practice Address - City:LYONS
Practice Address - State:CO
Practice Address - Zip Code:80540
Practice Address - Country:US
Practice Address - Phone:303-823-8813
Practice Address - Fax:303-823-2355
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO6185174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
487548Medicare ID - Type Unspecified