MEDICARE: KATELYN TAYLOR KELTNER PA

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	390200000X	Student in an Organized Health Care Education/Training Program
2	363A00000X	Physician Assistant	2020028651	MO

General Provider Information

NPI Number	:	1780211334
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATELYN TAYLOR KELTNER PA

Provider Business Mailing Address
First Line	:	303 N FOXRIDGE DR APT 205
Second Line	:
City	:	RAYMORE
State	:	MO
Zip	:	64083-7833
Country	:	US
Telephone Number	:	816-813-0607
Fax Number	:

Provider Business Practice Location Address
First Line	:	1950 DIAMOND PKWY
Second Line	:
City	:	NORTH KANSAS CITY
State	:	MO
Zip	:	64116-4328
Country	:	US
Telephone Number	:	816-561-3003
Fax Number	:	816-889-1584

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

Provider Enumeration Date	:	03/24/2020
Last Update Date	:	03/20/2023

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