Healthcare Provider Details

I. General information

NPI: 1538376389
Provider Name (Legal Business Name): MEGAN LEAH HERZOG GNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2007
Last Update Date: 11/10/2023
Certification Date: 11/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12600 W COLFAX AVE STE B200
LAKEWOOD CO
80215-3736
US

IV. Provider business mailing address

4211 ZODIAC PL
CASTLE ROCK CO
80109-3769
US

V. Phone/Fax

Practice location:
  • Phone: 303-459-4000
  • Fax:
Mailing address:
  • Phone: 952-288-5920
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number0995065-NP
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberR1675081
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: