Basic Information
| Provider Information | |||||||||
| NPI: | 1972835973 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CONNELL | ||||||||
| FirstName: | TRACEY | ||||||||
| MiddleName: | RENEE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LIM | ||||||||
| OtherFirstName: | TRACEY | ||||||||
| OtherMiddleName: | RENEE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5555 E ARAPAHOE RD | ||||||||
| Address2: | |||||||||
| City: | CENTENNIAL | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801222312 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3033384545 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5555 E ARAPAHOE RD | ||||||||
| Address2: | |||||||||
| City: | CENTENNIAL | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801222312 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3033384545 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/02/2010 | ||||||||
| LastUpdateDate: | 07/16/2012 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 2950 | CO | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 020852 | 01 | CO | KAISER COMMERCIAL NUMBER | OTHER | 37355031 | 05 | CO | MEDICAID |