Provider Demographics
NPI:1801878434
Name:VAN KONYNENBURG, KRISTIN (MD)
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:
Last Name:VAN KONYNENBURG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1067 S HOVER ST
Mailing Address - Street 2:UNIT E
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80501-7904
Mailing Address - Country:US
Mailing Address - Phone:720-253-5648
Mailing Address - Fax:
Practice Address - Street 1:600 S AIRPORT RD UNIT A203
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80503-6427
Practice Address - Country:US
Practice Address - Phone:303-776-0467
Practice Address - Fax:303-776-0387
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2021-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO42439207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO31238505Medicaid
COC546118Medicare PIN
CO31238505Medicaid