Healthcare Provider Details

I. General information

NPI: 1417692880
Provider Name (Legal Business Name): MR. ALEXANDER VAN KRUYSMAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2022
Last Update Date: 08/10/2023
Certification Date: 08/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

605 MIAMI RD
MONTROSE CO
81401-4108
US

IV. Provider business mailing address

PO BOX 1328
DURANGO CO
81302-1328
US

V. Phone/Fax

Practice location:
  • Phone: 970-252-3200
  • Fax:
Mailing address:
  • Phone: 970-335-2314
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number26051
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberC-APN.0100521-C-NP
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: