Provider Demographics
NPI:1134899800
Name:MEYERS, KENNETH GORDON JR (NP)
Entity type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:GORDON
Last Name:MEYERS
Suffix:JR
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 1:5935 NORTHWIND DR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80918-4809
Mailing Address - Country:US
Mailing Address - Phone:719-200-7589
Mailing Address - Fax:
Practice Address - Street 1:1605 N UNION BLVD
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909-2828
Practice Address - Country:US
Practice Address - Phone:719-635-3764
Practice Address - Fax:719-635-7593
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-15
Last Update Date:2024-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0996511363LA2200X, 363LG0600X, 363LP2300X, 251T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251T00000XAgenciesProgram of All-Inclusive Care for the Elderly (PACE) Provider Organization
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care