Provider Demographics
NPI:1497191464
Name:BUCKLEY, KELLY (PA-C)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:BUCKLEY
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 1:28770 PINE TRL
Mailing Address - Street 2:
Mailing Address - City:CONIFER
Mailing Address - State:CO
Mailing Address - Zip Code:80433-7226
Mailing Address - Country:US
Mailing Address - Phone:720-201-7422
Mailing Address - Fax:
Practice Address - Street 1:8111 S HOMESTEADER DR
Practice Address - Street 2:
Practice Address - City:MORRISON
Practice Address - State:CO
Practice Address - Zip Code:80465-2816
Practice Address - Country:US
Practice Address - Phone:720-201-7422
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-17
Last Update Date:2015-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO812363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant