Provider Demographics
NPI:1366467805
Name:BALLOU, KELLY (PA-C)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:BALLOU
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:GABA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:265 DILLON RIDGE RD
Mailing Address - Street 2:SUITE C402
Mailing Address - City:DILLON
Mailing Address - State:CO
Mailing Address - Zip Code:80435-6009
Mailing Address - Country:US
Mailing Address - Phone:309-287-1909
Mailing Address - Fax:
Practice Address - Street 1:60 MAIN STREET
Practice Address - Street 2:STE F,G,H BEAVER PLAZA CONDO
Practice Address - City:FRISCO
Practice Address - State:CO
Practice Address - Zip Code:80443
Practice Address - Country:US
Practice Address - Phone:309-287-1909
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2017-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA0004388363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q02483Medicare UPIN
IL207805Medicare PIN