Provider Demographics
NPI:1740583012
Name:NINOW, KELSEY J (PA)
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:J
Last Name:NINOW
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KELSEY
Other - Middle Name:J
Other - Last Name:LUNDEEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:7030 S YOSEMITE ST
Mailing Address - Street 2:
Mailing Address - City:CENTENNIAL
Mailing Address - State:CO
Mailing Address - Zip Code:80112-2026
Mailing Address - Country:US
Mailing Address - Phone:303-721-9984
Mailing Address - Fax:303-267-7304
Practice Address - Street 1:7030 S YOSEMITE ST
Practice Address - Street 2:
Practice Address - City:CENTENNIAL
Practice Address - State:CO
Practice Address - Zip Code:80112-2026
Practice Address - Country:US
Practice Address - Phone:303-721-9984
Practice Address - Fax:909-267-7304
Is Sole Proprietor?:No
Enumeration Date:2010-12-08
Last Update Date:2016-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO3120363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
COP01099664OtherRAILROAD MEDICARE PTAN
COCOAAA4343Medicare PIN