Provider Demographics
NPI:1730853581
Name:WINTER, MARIAH
Entity type:Individual
Prefix:MS
First Name:MARIAH
Middle Name:
Last Name:WINTER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1939 SPRUCE CT
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:CO
Mailing Address - Zip Code:80516-7977
Mailing Address - Country:US
Mailing Address - Phone:720-378-2227
Mailing Address - Fax:
Practice Address - Street 1:403 SUMMIT BLVD UNIT 204
Practice Address - Street 2:
Practice Address - City:BROOMFIELD
Practice Address - State:CO
Practice Address - Zip Code:80021-8253
Practice Address - Country:US
Practice Address - Phone:720-401-2139
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-05
Last Update Date:2022-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
COPA.0007044363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program