Provider Demographics
NPI:1093792020
Name:PERCY, KEVIN D (PAC)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:D
Last Name:PERCY
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:175 S UNION BLVD STE 300
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80910-3126
Mailing Address - Country:US
Mailing Address - Phone:719-365-1950
Mailing Address - Fax:719-365-1951
Practice Address - Street 1:175 S UNION BLVD STE 300
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80910-3126
Practice Address - Country:US
Practice Address - Phone:719-365-1950
Practice Address - Fax:719-365-1951
Is Sole Proprietor?:No
Enumeration Date:2005-12-30
Last Update Date:2019-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO773363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO96880759Medicaid
CO96880759Medicaid
COC488918Medicare PIN