Healthcare Provider Details

I. General information

NPI: 1477691657
Provider Name (Legal Business Name): LON GRANT KIRT PHYSICIAN ASSISTANT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/01/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1650 COCHRANE CIR
FT CARSON CO
80913-4603
US

IV. Provider business mailing address

5964 BESTVIEW WAY
COLORADO SPRINGS CO
80918-4815
US

V. Phone/Fax

Practice location:
  • Phone: 719-524-3520
  • Fax: 719-524-3526
Mailing address:
  • Phone: 719-548-9180
  • Fax: 719-548-9180

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: