Provider Demographics
NPI:1891836433
Name:DEIDEL, KELLY (PA)
Entity Type:Individual
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First Name:KELLY
Middle Name:
Last Name:DEIDEL
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Gender:F
Credentials:PA
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Mailing Address - Street 1:9094 E MINERAL CIR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CENTENNIAL
Mailing Address - State:CO
Mailing Address - Zip Code:80112-7200
Mailing Address - Country:US
Mailing Address - Phone:303-694-3200
Mailing Address - Fax:303-694-2680
Practice Address - Street 1:9094 E MINERAL CIR
Practice Address - Street 2:SUITE 100
Practice Address - City:CENTENNIAL
Practice Address - State:CO
Practice Address - Zip Code:80112-7200
Practice Address - Country:US
Practice Address - Phone:303-694-3200
Practice Address - Fax:303-694-2680
Is Sole Proprietor?:No
Enumeration Date:2007-02-08
Last Update Date:2017-08-07
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Provider Licenses
StateLicense IDTaxonomies
CO2265363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical