Healthcare Provider Details

I. General information

NPI: 1386708501
Provider Name (Legal Business Name): TIM L KYNION PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/21/2006
Last Update Date: 06/12/2026
Certification Date: 06/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1033 2ND AVE
MONTE VISTA CO
81144-1737
US

IV. Provider business mailing address

1033 2ND AVE
MONTE VISTA CO
81144-1737
US

V. Phone/Fax

Practice location:
  • Phone: 719-852-8827
  • Fax:
Mailing address:
  • Phone: 719-852-8827
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA.0002767
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: