Provider Demographics
NPI:1598190530
Name:KELL, TYLER GLEN (PA-C)
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:GLEN
Last Name:KELL
Suffix:
Gender:M
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 1:20805 W 151ST ST
Mailing Address - Street 2:SUITE 224
Mailing Address - City:OLATHE
Mailing Address - State:KS
Mailing Address - Zip Code:66061-7249
Mailing Address - Country:US
Mailing Address - Phone:913-782-8300
Mailing Address - Fax:913-782-1574
Practice Address - Street 1:20805 W 151ST ST
Practice Address - Street 2:SUITE 224
Practice Address - City:OLATHE
Practice Address - State:KS
Practice Address - Zip Code:66061-7249
Practice Address - Country:US
Practice Address - Phone:913-782-8300
Practice Address - Fax:913-782-1574
Is Sole Proprietor?:No
Enumeration Date:2013-09-10
Last Update Date:2014-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS15-01699363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS033D00107Medicare PIN
MOP01269228OtherRAILROAD MEDICARE PTAN