Provider Demographics
NPI:1386066462
Name:CARDENAS PONCE, CECILIO (NP-C)
Entity type:Individual
Prefix:
First Name:CECILIO
Middle Name:
Last Name:CARDENAS PONCE
Suffix:
Gender:M
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1880 OFFICE CLUB PT STE 235
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80920-5017
Mailing Address - Country:US
Mailing Address - Phone:719-200-2243
Mailing Address - Fax:833-216-0396
Practice Address - Street 1:1880 OFFICE CLUB PT STE 235
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80920-5017
Practice Address - Country:US
Practice Address - Phone:719-200-2243
Practice Address - Fax:833-216-0396
Is Sole Proprietor?:No
Enumeration Date:2014-01-09
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP124870363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX347652YKP5Medicare PIN