Provider Demographics
NPI:1851651657
Name:KENYON, NATHAN TIMOTHY (MD)
Entity type:Individual
Prefix:
First Name:NATHAN
Middle Name:TIMOTHY
Last Name:KENYON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2505 MISSION DR STE 200
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65109-9508
Mailing Address - Country:US
Mailing Address - Phone:573-681-3759
Mailing Address - Fax:573-681-3659
Practice Address - Street 1:2505 MISSION DR STE 200
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65109-9508
Practice Address - Country:US
Practice Address - Phone:573-681-3759
Practice Address - Fax:573-681-3659
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-25
Last Update Date:2018-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013018167208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation