Provider Demographics
NPI:1477799310
Name:ONEILL, KELLY (PA-C)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:ONEILL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13650 E MISSISSIPPI AVE
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80012-3561
Mailing Address - Country:US
Mailing Address - Phone:303-695-8684
Mailing Address - Fax:
Practice Address - Street 1:13650 E MISSISSIPPI AVE
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80012-3561
Practice Address - Country:US
Practice Address - Phone:303-695-8684
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-24
Last Update Date:2020-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1038363A00000X
COPA.0003100363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT1477799310Medicaid
MT0000901753OtherBLUE CROSS BLUE SHIELD OF MONTANA