MEDICARE: MS. KELLY R GORDON RN ARNP CRNA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	367500000X	Certified Registered Nurse Anesthetist	54723	KS
2	163W00000X	Registered Nurse	1358880051	KS
3	163W00000X	Registered Nurse	115622	MO
4	367500000X	Certified Registered Nurse Anesthetist	115622	MO

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
7	P00401683	OTHER	KS	RAILROAD MEDICARE
10	P00365458	OTHER	MO	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	5718942	OTHER		FIRST HEALTH
2	28034048	OTHER	MO	BLUE CROSS BLUE SHIELD KC
3	66048A019	OTHER	KS	TRICARE WPS
4	145353	OTHER	KS	BLUE CROSS BLUE SHIELD KS
5	100016620001	OTHER		COMMUNITY HEALTH PLAN
6	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
8	00S23683	OTHER	KS	PREFERRED HEALTH SYSTEMS
9	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1063495711
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. KELLY R GORDON RN ARNP CRNA

Provider Business Mailing Address
First Line	:	29800 W 127TH ST
Second Line	:
City	:	OLATHE
State	:	KS
Zip	:	66061-8636
Country	:	US
Telephone Number	:	913-522-0889
Fax Number	:

Provider Business Practice Location Address
First Line	:	1318 E 104TH ST
Second Line	:
City	:	KANSAS CITY
State	:	MO
Zip	:	64131-4504
Country	:	US
Telephone Number	:	816-256-5200
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/28/2005
Last Update Date	:	05/01/2025

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