Basic Information
Provider Information | |||||||||
NPI: | 1669795571 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PERRY | ||||||||
FirstName: | KELLI | ||||||||
MiddleName: | JEAN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | EBERHARDT | ||||||||
OtherFirstName: | KELLI | ||||||||
OtherMiddleName: | JEAN | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PA-C | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1707 COLE BLVD. | ||||||||
Address2: | STE #100 | ||||||||
City: | GOLDEN | ||||||||
State: | CO | ||||||||
PostalCode: | 80401 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3037168018 | ||||||||
FaxNumber: | 3037635495 | ||||||||
Practice Location | |||||||||
Address1: | 165 S. UNION BLVD. | ||||||||
Address2: | STE #800 | ||||||||
City: | LAKEWOOD | ||||||||
State: | CO | ||||||||
PostalCode: | 80228 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3039882680 | ||||||||
FaxNumber: | 3039868057 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/05/2010 | ||||||||
LastUpdateDate: | 02/16/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 1846 | CO | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
ID Information
ID | Type | State | Issuer | Description | 18170340 | 05 | CO |   | MEDICAID |