Provider Demographics
NPI:1942859152
Name:HYMAN, KENNETH SHANE
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:SHANE
Last Name:HYMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10272 HIDDEN PARK WAY
Mailing Address - Street 2:
Mailing Address - City:PEYTON
Mailing Address - State:CO
Mailing Address - Zip Code:80831-8353
Mailing Address - Country:US
Mailing Address - Phone:903-276-2528
Mailing Address - Fax:
Practice Address - Street 1:10272 HIDDEN PARK WAY
Practice Address - Street 2:
Practice Address - City:PEYTON
Practice Address - State:CO
Practice Address - Zip Code:80831-8353
Practice Address - Country:US
Practice Address - Phone:903-276-2528
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-10
Last Update Date:2019-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COAPN.0995047-NP363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner