Provider Demographics
NPI:1730130337
Name:KISSELL, LAURA C (MD)
Entity Type:Individual
Prefix:DR
First Name:LAURA
Middle Name:C
Last Name:KISSELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2695 ROCKY MOUNTAIN AVE STE 150
Mailing Address - Street 2:
Mailing Address - City:LOVELAND
Mailing Address - State:CO
Mailing Address - Zip Code:80538-9071
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1400 E BOULDER ST STE 600
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909-5533
Practice Address - Country:US
Practice Address - Phone:719-364-6487
Practice Address - Fax:719-364-8347
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2020-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO445382086S0129X
NC2004006942086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
COCOA109844OtherMEDICARE INDIVIDUAL PTAN
NC200400694OtherPHYSICIAN LICENSE
CO44538OtherPHYSICIAN LICENSE
805636OtherMEDICARE ID
NC200400694OtherPHYSICIAN LICENSE
CO44538OtherPHYSICIAN LICENSE