Provider Demographics
NPI:1336440585
Name:YOON, COLLEEN KELLEY (PA)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:KELLEY
Last Name:YOON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:4750 HEMPSTEAD STATION DR
Mailing Address - Street 2:
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45429-5164
Mailing Address - Country:US
Mailing Address - Phone:800-875-0136
Mailing Address - Fax:937-619-4150
Practice Address - Street 1:16901 LAKESIDE HILLS CT
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68130-2318
Practice Address - Country:US
Practice Address - Phone:402-717-8000
Practice Address - Fax:937-619-4150
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-04
Last Update Date:2020-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010035961207P00000X, 363A00000X
MO2018015950363A00000X
NE1750363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO147480052Medicare PIN
MO147400050Medicare PIN