Provider Demographics
NPI:1013969518
Name:KINNAN, KELLY GAIL (MD)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:GAIL
Last Name:KINNAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:GAIL
Other - Last Name:SWANSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1700 HIGHWAY 25 N
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:MN
Mailing Address - Zip Code:55313-1930
Mailing Address - Country:US
Mailing Address - Phone:763-682-1313
Mailing Address - Fax:
Practice Address - Street 1:1700 HIGHWAY 25 N
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:MN
Practice Address - Zip Code:55313-1930
Practice Address - Country:US
Practice Address - Phone:763-682-1313
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2008-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN47793207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN080016114OtherMEDICARE-WPS
MN094H0SWOtherBCBS OF MN
MN2435604OtherAMERICA'S PPO
MNHP61506OtherHEALTHPARTNERS
MN1014268OtherPREFERRED ONE
MN176473000Medicaid
MN6609467OtherMEDICA UC# FOR APC