Provider Demographics
NPI:1568836674
Name:STRACK, KELLY (PA-C)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:STRACK
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 1:181 W MEADOW DR STE 400
Mailing Address - Street 2:
Mailing Address - City:VAIL
Mailing Address - State:CO
Mailing Address - Zip Code:81657-5058
Mailing Address - Country:US
Mailing Address - Phone:970-401-8767
Mailing Address - Fax:970-237-3458
Practice Address - Street 1:181 W MEADOW DR STE 400
Practice Address - Street 2:
Practice Address - City:VAIL
Practice Address - State:CO
Practice Address - Zip Code:81657-5058
Practice Address - Country:US
Practice Address - Phone:970-401-8767
Practice Address - Fax:970-237-3458
Is Sole Proprietor?:No
Enumeration Date:2015-12-01
Last Update Date:2022-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA.0004925363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant