Healthcare Provider Details

I. General information

NPI: 1336440585
Provider Name (Legal Business Name): COLLEEN KELLEY YOON PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/04/2010
Last Update Date: 04/22/2020
Certification Date: 04/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16901 LAKESIDE HILLS CT
OMAHA NE
68130-2318
US

IV. Provider business mailing address

4750 HEMPSTEAD STATION DR
KETTERING OH
45429-5164
US

V. Phone/Fax

Practice location:
  • Phone: 402-717-8000
  • Fax: 937-619-4150
Mailing address:
  • Phone: 800-875-0136
  • Fax: 937-619-4150

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number2010035961
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2018015950
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2010035961
License Number StateMO
# 4
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1750
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: