Provider Demographics
NPI:1861430928
Name:MONLEZUN, MALCOLM JOSEPH (CRNA)
Entity type:Individual
Prefix:
First Name:MALCOLM
Middle Name:JOSEPH
Last Name:MONLEZUN
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:MALCOLM
Other - Middle Name:J
Other - Last Name:MONLEZUN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CRNA
Mailing Address - Street 1:13601 N 115TH ST
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80504-8017
Mailing Address - Country:US
Mailing Address - Phone:303-915-2269
Mailing Address - Fax:866-663-6555
Practice Address - Street 1:13601 N 115TH ST
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80504-8017
Practice Address - Country:US
Practice Address - Phone:303-915-2269
Practice Address - Fax:866-663-6555
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-02
Last Update Date:2013-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO160578367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO41535545Medicaid
COCO41326Medicare PIN
CO41535545Medicaid