Basic Information
| Provider Information | |||||||||
| NPI: | 1457958688 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | IRWIN | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | DR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 913 VILLAGE RD | ||||||||
| Address2: | |||||||||
| City: | CARBONDALE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 816231567 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9709487982 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1378 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | CARBONDALE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 816231840 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9709636600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/01/2020 | ||||||||
| LastUpdateDate: | 10/01/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PTL.0017225 | CO | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.