Provider Demographics
NPI:1063495711
Name:GORDON, KELLY R (RN ARNP CRNA)
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:R
Last Name:GORDON
Suffix:
Gender:F
Credentials:RN ARNP CRNA
Other - Prefix:MS
Other - First Name:KELLY
Other - Middle Name:R
Other - Last Name:HUTTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3705 N 139TH ST
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:KS
Mailing Address - Zip Code:66109-4234
Mailing Address - Country:US
Mailing Address - Phone:913-721-3641
Mailing Address - Fax:913-721-3649
Practice Address - Street 1:3310 W 10TH ST
Practice Address - Street 2:
Practice Address - City:SEDALIA
Practice Address - State:MO
Practice Address - Zip Code:65301-2111
Practice Address - Country:US
Practice Address - Phone:660-829-4024
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-28
Last Update Date:2019-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1358880051163W00000X
MO115622163W00000X, 367500000X
KS54723363L00000X, 367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS00S23683OtherPREFERRED HEALTH SYSTEMS
MO28034048OtherBLUE CROSS BLUE SHIELD KC
KSP00401683OtherRAILROAD MEDICARE
5718942OtherFIRST HEALTH
KS145353OtherBLUE CROSS BLUE SHIELD KS
100016620001OtherCOMMUNITY HEALTH PLAN
KS66048A019OtherTRICARE WPS
MO915400618Medicaid
KS100403160DMedicaid
MOP00365458OtherRAILROAD MEDICARE
KS100403160DMedicaid
KS145353Medicare PIN
KSP00401683OtherRAILROAD MEDICARE
KS66048A019OtherTRICARE WPS
P15852Medicare UPIN