Basic Information
| Provider Information | |||||||||
| NPI: | 1275754202 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ANDRA | ||||||||
| FirstName: | KELLY | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10787 NALL AVE | ||||||||
| Address2: | SUITE 310 | ||||||||
| City: | OVERLAND PARK | ||||||||
| State: | KS | ||||||||
| PostalCode: | 662111375 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9139456900 | ||||||||
| FaxNumber: | 9139456970 | ||||||||
| Practice Location | |||||||||
| Address1: | 10787 NALL AVE | ||||||||
| Address2: | SUITE 310 | ||||||||
| City: | OVERLAND PARK | ||||||||
| State: | KS | ||||||||
| PostalCode: | 662111375 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9139456900 | ||||||||
| FaxNumber: | 9139456970 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/01/2007 | ||||||||
| LastUpdateDate: | 02/03/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 2007015074 | MO | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 0438218 | KS | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 205481609 | 05 | MO | MEDICAID |