Provider Demographics
NPI:1538150966
Name:BENNER, DAVID CRISTOPHER
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:CRISTOPHER
Last Name:BENNER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:DAVID
Other - Middle Name:
Other - Last Name:BENNER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 173894
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80217-3894
Mailing Address - Country:US
Mailing Address - Phone:303-306-7783
Mailing Address - Fax:303-306-7753
Practice Address - Street 1:1100 BALSAM AVE
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80304-3404
Practice Address - Country:US
Practice Address - Phone:303-440-2001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-03
Last Update Date:2013-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2965363A00000X
CAPA17737364SE0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No364SE0003XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistEmergency
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOPA177370Medicaid
CO36352861Medicaid
CO36352861Medicaid
COCO307322Medicare PIN
CAOPA177370Medicare ID - Type Unspecified