Healthcare Provider Details

I. General information

NPI: 1740791623
Provider Name (Legal Business Name): KELLY GAYDOSH PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2017
Last Update Date: 12/12/2025
Certification Date: 12/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11750 W 2ND PL STE 160
LAKEWOOD CO
80228-1724
US

IV. Provider business mailing address

7951 E MAPLEWOOD AVE STE 350
GREENWOOD VILLAGE CO
80111-4758
US

V. Phone/Fax

Practice location:
  • Phone: 303-430-2700
  • Fax: 303-430-2770
Mailing address:
  • Phone: 303-930-7803
  • Fax: 303-930-5503

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA.0006502
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: