Healthcare Provider Details

I. General information

NPI: 1225091788
Provider Name (Legal Business Name): KELLY ANN PETERS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2006
Last Update Date: 03/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10103 RIDGEGATE PKWY 312
LONE TREE CO
80124-5525
US

IV. Provider business mailing address

10103 RIDGEGATE PKWY 312
LONE TREE CO
80124-5525
US

V. Phone/Fax

Practice location:
  • Phone: 303-788-8888
  • Fax: 303-790-2567
Mailing address:
  • Phone: 303-788-8888
  • Fax: 303-790-2567

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number2166
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2166
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: