Provider Demographics
NPI:1639751506
Name:RISSMILLER, KELLE A (PA-C)
Entity Type:Individual
Prefix:
First Name:KELLE
Middle Name:A
Last Name:RISSMILLER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KELLE
Other - Middle Name:
Other - Last Name:LYSINGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2255 S ONEIDA ST
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80224-2522
Mailing Address - Country:US
Mailing Address - Phone:303-360-6276
Mailing Address - Fax:303-789-7222
Practice Address - Street 1:19964 HILLTOP RD STE A
Practice Address - Street 2:
Practice Address - City:PARKER
Practice Address - State:CO
Practice Address - Zip Code:80134-7316
Practice Address - Country:US
Practice Address - Phone:303-841-2212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-21
Last Update Date:2021-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA.0006734363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant