Provider Demographics
NPI:1275754202
Name:ANDRA, KELLY (MD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:ANDRA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10787 NALL AVE
Mailing Address - Street 2:SUITE 310
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66211-1375
Mailing Address - Country:US
Mailing Address - Phone:913-945-6900
Mailing Address - Fax:913-945-6970
Practice Address - Street 1:10787 NALL AVE
Practice Address - Street 2:SUITE 310
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66211-1375
Practice Address - Country:US
Practice Address - Phone:913-945-6900
Practice Address - Fax:913-945-6970
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2017-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2007015074207R00000X
KS0438218207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO205481609Medicaid
KSJ61A00084Medicare PIN
MO205481609Medicaid