Basic Information
Provider Information | |||||||||
NPI: | 1912550989 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | IM | ||||||||
FirstName: | CAROLYN | ||||||||
MiddleName: | S | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1805 SHEA CENTER DR STE 301 | ||||||||
Address2: |   | ||||||||
City: | HIGHLANDS RANCH | ||||||||
State: | CO | ||||||||
PostalCode: | 801292277 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7204939006 | ||||||||
FaxNumber: | 7202427520 | ||||||||
Practice Location | |||||||||
Address1: | 9218 KIMMER DR STE 207 | ||||||||
Address2: |   | ||||||||
City: | LONE TREE | ||||||||
State: | CO | ||||||||
PostalCode: | 801246733 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7204939006 | ||||||||
FaxNumber: | 7202427520 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/19/2019 | ||||||||
LastUpdateDate: | 07/14/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/14/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 4939 | WI | N |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   | 363A00000X | PA.0006728 | CO | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
ID Information
ID | Type | State | Issuer | Description | 100096114 | 05 | WI |   | MEDICAID |