Healthcare Provider Details

I. General information

NPI: 1780241679
Provider Name (Legal Business Name): KENDRA WALKER TAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KENDRA MONTAYNE WALKER

II. Dates (important events)

Enumeration Date: 05/25/2019
Last Update Date: 08/27/2024
Certification Date: 08/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2060 BRIARGATE PKWY STE 150
COLORADO SPRINGS CO
80920-7660
US

IV. Provider business mailing address

200 HAWKINS DR DEPT INTERNAL
IOWA CITY IA
52242-1009
US

V. Phone/Fax

Practice location:
  • Phone: 719-471-1763
  • Fax: 719-471-2498
Mailing address:
  • Phone: 319-467-2000
  • Fax: 319-384-8955

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberMD-49793
License Number StateIA
# 2
Primary TaxonomyY
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License NumberDR.0073399
License Number StateCO
# 3
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License NumberMD-49793
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: