NPIMap

Individual provider Active NPI

Queenter Kisang, MD

  • Family Medicine Physician
  • Pueblo, CO
National Provider Identifier
1033773627
Registry record updated May 20, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
License
DR.006687 Issued in CO
Practice address
3676 Parker Blvd
Pueblo, CO 81008-2212
Phone
(719) 553-1804
Fax
(833) 916-2047
NPI assigned
Apr 29, 2019
Last updated
May 20, 2024By the provider in NPPES
Sex
Female
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on May 20, 2024

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine Physician 207Q00000X DR.006687 CO Primary

Addresses

Primary practice location

3676 Parker Blvd
Pueblo, CO 81008-2212

Mailing address

PO Box 9000
Pueblo, CO 81008-9000
Phone (719) 553-1804

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in CO
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20231218002419 CO Practitioner - Family Practice 9335473578 Reassigns benefits to 1 organization

Care Compare profile

Medicare Care Compare
Specialty
Family Practice
Education
Other, 2019
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices
Southern Colorado Clinic PCGroup PAC ID 4284524067, 36 clinicians

Practice addresses (Care Compare)

109 S Burlington Dr
Pueblo West, CO 81007-5549
Phone (719) 553-2200

Hospital & facility affiliations

Procedures performed for Medicare patients

ProcedureNumber of procedures
Removal of tissue1-10
Removal of skin lesions1-10
Removal of nail tissue12
Removal or shaving of skin growth1-10
Skin biopsy1-10

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Doctor of Medicine

State licenses

LicenseStateTypeSpecialty
DR.006687COMDFamily Medicine Physician

Practice roles

OrganizationSpecialtyStatusNew patients
Southern Colorado Clinic PC CurrentSince May 24, 2024 Accepting new patients

Locations

3676 Parker Blvd
Pueblo, CO 81008
Phone (719) 253-7000

3676 Parker Blvd
Ste 290
Pueblo, CO 81008
Phone (719) 553-2200

3676 Parker Blvd
Ste 370
Pueblo, CO 81008
Phone (719) 553-2209

109 S Burlington Dr
Pueblo West, CO 81007
Phone (719) 766-9000

Networks

  • CO HMO
  • devoted network organization-a4751131-f16f-4e82-8f2b-b08e66379a7a
  • CO HMO D-SNP
  • CO HMO C-SNP

Interoperability endpoints

  • Direct secure messaging: queenter.kisang.1@21306.direct.athenahealth.com

Organizations & group practices 1

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

Hospital & facility affiliations 10

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1556496000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1716163200000",
    "number": "1033773627",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 9000",
            "city": "PUEBLO",
            "state": "CO",
            "postal_code": "810089000",
            "telephone_number": "719-553-1804"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3676 PARKER BLVD",
            "city": "PUEBLO",
            "state": "CO",
            "postal_code": "810082212",
            "telephone_number": "719-553-1804",
            "fax_number": "833-916-2047"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "KISANG",
        "first_name": "QUEENTER",
        "name_prefix": "Dr.",
        "credential": "MD",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2019-04-29",
        "last_updated": "2024-05-20",
        "certification_date": "2024-05-20",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "CO",
            "license": "DR.006687",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Pueblo, CO

Sources for this page

Verify at the official NPI Registry.