Provider Demographics
NPI:1013356922
Name:GRECO, KELLY C (PAC)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:C
Last Name:GRECO
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 OSBORNE RD NE DEPT OF
Mailing Address - Street 2:
Mailing Address - City:FRIDLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55432-2765
Mailing Address - Country:US
Mailing Address - Phone:763-786-6011
Mailing Address - Fax:763-684-2505
Practice Address - Street 1:3800 PARK NICOLLET BLVD
Practice Address - Street 2:DEPARTMENT OF DERMATOLOGY
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416-2527
Practice Address - Country:US
Practice Address - Phone:952-993-3260
Practice Address - Fax:952-993-0333
Is Sole Proprietor?:No
Enumeration Date:2013-06-25
Last Update Date:2021-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI363A00000X
MN11710363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant