Provider Demographics
NPI:1942269873
Name:KELLY, DONALD R (PA)
Entity Type:Individual
Prefix:MR
First Name:DONALD
Middle Name:R
Last Name:KELLY
Suffix:
Gender:M
Credentials:PA
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Mailing Address - Street 1:2121 E HARMONY RD
Mailing Address - Street 2:STE 330
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80528-3400
Mailing Address - Country:US
Mailing Address - Phone:970-221-5878
Mailing Address - Fax:970-221-3564
Practice Address - Street 1:2121 E HARMONY RD
Practice Address - Street 2:STE 330
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80528-3400
Practice Address - Country:US
Practice Address - Phone:970-221-5878
Practice Address - Fax:970-221-3564
Is Sole Proprietor?:No
Enumeration Date:2006-03-20
Last Update Date:2014-12-26
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Provider Licenses
StateLicense IDTaxonomies
CO747363AS0400X
COPA.0000747363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO07007479Medicaid
COP01052988OtherRR MEDICARE
CO07007479Medicaid
COP01052988OtherRR MEDICARE