Healthcare Provider Details

I. General information

NPI: 1942868005
Provider Name (Legal Business Name): KELLI ANNE POPLAU PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2019
Last Update Date: 06/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

715 N SAINT JOSEPH AVE
HASTINGS NE
68901-4451
US

IV. Provider business mailing address

934 TILDEN AVE
HASTINGS NE
68901-3561
US

V. Phone/Fax

Practice location:
  • Phone: 402-463-4521
  • Fax:
Mailing address:
  • Phone: 402-460-7236
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2371
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: