Provider Demographics
NPI:1982670030
Name:ADAMS, KELLY J (PA)
Entity Type:Individual
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First Name:KELLY
Middle Name:J
Last Name:ADAMS
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Gender:F
Credentials:PA
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Mailing Address - Street 1:8100 34TH AVE S
Mailing Address - Street 2:MC21110Q
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55425-1672
Mailing Address - Country:US
Mailing Address - Phone:952-883-7172
Mailing Address - Fax:952-883-5395
Practice Address - Street 1:640 JACKSON ST
Practice Address - Street 2:MC 11102F
Practice Address - City:ST PAUL
Practice Address - State:MN
Practice Address - Zip Code:55101-2502
Practice Address - Country:US
Practice Address - Phone:651-254-3456
Practice Address - Fax:651-254-5216
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-28
Last Update Date:2007-07-08
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Provider Licenses
StateLicense IDTaxonomies
MN9465363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P28670Medicare UPIN