Provider Demographics
NPI:1417189630
Name:MCKERNAN, KRISTEN BETH (PT)
Entity Type:Individual
Prefix:MRS
First Name:KRISTEN
Middle Name:BETH
Last Name:MCKERNAN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6234 OLDE STAGE RD
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80302-9498
Mailing Address - Country:US
Mailing Address - Phone:720-545-6179
Mailing Address - Fax:866-568-6675
Practice Address - Street 1:6234 OLDE STAGE RD
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80302-9498
Practice Address - Country:US
Practice Address - Phone:720-545-6179
Practice Address - Fax:866-568-6675
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-20
Last Update Date:2013-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO11189225100000X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO11189OtherCOLORADO PHYSICAL THERAPY LICENSE NUMBER
CO310429YUHFMedicare UPIN