Healthcare Provider Details

I. General information

NPI: 1134899800
Provider Name (Legal Business Name): KENNETH GORDON MEYERS JR. NP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/15/2021
Last Update Date: 09/10/2026
Certification Date: 09/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1605 N UNION BLVD
COLORADO SPRINGS CO
80909-2828
US

IV. Provider business mailing address

3205 N ACADEMY BLVD STE 130
COLORADO SPRINGS CO
80917-5152
US

V. Phone/Fax

Practice location:
  • Phone: 719-635-3764
  • Fax: 719-635-7593
Mailing address:
  • Phone: 719-632-5700
  • Fax: 719-344-7819

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number0996511
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code251T00000X
TaxonomyPACE Provider Organization
License Number0996511
License Number StateCO
# 3
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number0996511
License Number StateCO
# 4
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number0996511
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: