NPIMap

Individual provider Active NPI

Nathan Roesner, D.O.

  • Surgery Physician
  • Boulder, CO
National Provider Identifier
1598886483
Registry record updated Oct 20, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Surgery PhysicianTaxonomy code 208600000X
License
50492 Issued in CO
Practice address
2595 Canyon Blvd Ste 360
Boulder, CO 80302-6745
Phone
(303) 440-7546
NPI assigned
Apr 2, 2007
Sex
Male
Sole proprietor
Yes

NPPES NPI Registry

Updated by the provider on Oct 20, 2021

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Surgery Physician 208600000X 5101017089 MI
Surgery Physician 208600000X 50492 CO Primary

Addresses

Primary practice location

2595 Canyon Blvd Ste 360
Boulder, CO 80302-6745

Mailing address

11700 W 2ND PL
Medical Plaza 2 Ste 210
Lakewood, CO 80228-1704
Phone (303) 909-6977

Other identifiers 1

IdentifierTypeStateIssuer
75531267MedicaidCO

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in CO
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20120830000454 CO Practitioner - Plastic and Reconstructive Surgery 4385891100 Reassigns benefits to 1 organization

Care Compare profile

Medicare Care Compare
Specialty
Plastic and Reconstructive Surgery
Education
Other, 2005
Medicare assignment
May accept Medicare assignment

Practice addresses (Care Compare)

2595 Canyon Blvd
Boulder, CO 80302-6745

Hospital & facility affiliations

  • Adventhealth Avista Hospital, Louisville, CO, CCN 060103

Procedures performed for Medicare patients

ProcedureNumber of procedures
Mastectomy17
Removal of tissue1-10

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Doctor of Osteopathy

State licenses

LicenseStateTypeSpecialty
50492COMDSurgery Physician
5101017089MIMDSurgery Physician

Practice roles

OrganizationSpecialtyStatusNew patients
Mile High Plastic Surgery a Professional LLC CurrentSince Jan 1, 2012 Accepting new patients
Avanti Skin Center of Boulder PastSince Oct 24, 2021 Accepting new patients

Locations

2595 Canyon Blvd
Ste 360
Boulder, CO 80302
Phone (303) 440-7546

3464 S Willow St
Ste 767
Denver, CO 80231

11700 W 2nd Pl
Ste 210
Lakewood, CO 80228
Phone (720) 321-8080

Organizations & group practices 2

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

Hospital & facility affiliations 9

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1175472000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1634688000000",
    "number": "1598886483",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "11700 W 2ND PL",
            "address_2": "MEDICAL PLAZA 2 STE 210",
            "city": "LAKEWOOD",
            "state": "CO",
            "postal_code": "802281704",
            "telephone_number": "303-909-6977",
            "fax_number": "303-954-4779"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2595 CANYON BLVD STE 360",
            "city": "BOULDER",
            "state": "CO",
            "postal_code": "803026745",
            "telephone_number": "303-440-7546"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "ROESNER",
        "first_name": "NATHAN",
        "name_prefix": "Dr.",
        "credential": "D.O.",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2007-04-02",
        "last_updated": "2021-10-20",
        "certification_date": "2021-10-20",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "208600000X",
            "taxonomy_group": "",
            "desc": "Surgery",
            "state": "MI",
            "license": "5101017089",
            "primary": false
        },
        {
            "code": "208600000X",
            "taxonomy_group": "",
            "desc": "Surgery",
            "state": "CO",
            "license": "50492",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "75531267",
            "state": "CO"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Boulder, CO

Sources for this page

Verify at the official NPI Registry.