Basic Information
| Provider Information | |||||||||
| NPI: | 1942269873 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KELLY | ||||||||
| FirstName: | DONALD | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2121 E HARMONY RD | ||||||||
| Address2: | STE 330 | ||||||||
| City: | FORT COLLINS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805283400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9702215878 | ||||||||
| FaxNumber: | 9702213564 | ||||||||
| Practice Location | |||||||||
| Address1: | 2121 E HARMONY RD | ||||||||
| Address2: | STE 330 | ||||||||
| City: | FORT COLLINS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805283400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9702215878 | ||||||||
| FaxNumber: | 9702213564 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2006 | ||||||||
| LastUpdateDate: | 12/26/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | 747 | CO | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363A00000X | PA.0000747 | CO | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 07007479 | 05 | CO | MEDICAID | P01052988 | 01 | CO | RR MEDICARE | OTHER |