MEDICARE: KAITLYN LAUREL PELL PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207N00000X	Dermatology Physician	PA.0005427	CO
2	208200000X	Plastic Surgery Physician	PA.0005427	CO

General Provider Information

NPI Number	:	1326521576
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KAITLYN LAUREL PELL PA-C

Provider Business Mailing Address
First Line	:	125 INVERNESS DR E STE 340
Second Line	:
City	:	ENGLEWOOD
State	:	CO
Zip	:	80112-5139
Country	:	US
Telephone Number	:	303-747-6719
Fax Number	:	303-951-0578

Provider Business Practice Location Address
First Line	:	125 INVERNESS DR E STE 340
Second Line	:
City	:	ENGLEWOOD
State	:	CO
Zip	:	80112-5139
Country	:	US
Telephone Number	:	303-747-6719
Fax Number	:	303-951-0578

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/13/2018
Last Update Date	:	09/13/2018

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