Provider Demographics
NPI:1346858404
Name:GRIEGO, KEENAN MICHAEL (NP)
Entity Type:Individual
Prefix:
First Name:KEENAN
Middle Name:MICHAEL
Last Name:GRIEGO
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5127
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98206-5127
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5410 POWERS CENTER PT STE 230
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80920-7148
Practice Address - Country:US
Practice Address - Phone:719-282-6100
Practice Address - Fax:719-282-6106
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-15
Last Update Date:2023-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COAPN.0998159-NP363LG0600X
WAAP61085301363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology