Provider Demographics
NPI:1245268754
Name:KELLY, COLLEEN R (PA)
Entity type:Individual
Prefix:
First Name:COLLEEN
Middle Name:R
Last Name:KELLY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:COLLEEN
Other - Middle Name:R
Other - Last Name:KELLY-PERKINS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:12639 OLD TESSON RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63128-2786
Mailing Address - Country:US
Mailing Address - Phone:314-849-0311
Mailing Address - Fax:314-849-4423
Practice Address - Street 1:3651 COLLEGE BLVD
Practice Address - Street 2:
Practice Address - City:LEAWOOD
Practice Address - State:KS
Practice Address - Zip Code:66211-1910
Practice Address - Country:US
Practice Address - Phone:913-319-7633
Practice Address - Fax:913-253-1764
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2019-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
MO119557363AS0400X
KS1500630363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS40122016OtherBCBS-KC
MOMA3774002Medicare PIN
KS0447460003Medicare NSC
KSKA2451001Medicare PIN
KS40122016OtherBCBS-KC