Healthcare Provider Details

I. General information

NPI: 1639751506
Provider Name (Legal Business Name): KELLE A RISSMILLER PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KELLE LYSINGER

II. Dates (important events)

Enumeration Date: 04/21/2021
Last Update Date: 10/13/2021
Certification Date: 10/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19964 HILLTOP RD STE A
PARKER CO
80134-7316
US

IV. Provider business mailing address

2255 S ONEIDA ST
DENVER CO
80224-2522
US

V. Phone/Fax

Practice location:
  • Phone: 303-841-2212
  • Fax:
Mailing address:
  • Phone: 303-360-6276
  • Fax: 303-789-7222

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA.0006734
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: