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NPI Code Detail

MEDICARE: KELLY WITUCKI PA-C

MEDICARE: KELLY WITUCKI PA-C
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
1363A00000XPhysician Assistant15652MN

General Provider Information

NPI Number : 1649150822
Entity Type Code : Individual
Provider Name (Legal Business Name) : KELLY WITUCKI PA-C
Provider Business Mailing Address
First Line : 2829 UNIVERSITY AVE SE STE 730
Second Line :
City : MINNEAPOLIS
State : MN
Zip : 55414-3279
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 1575 BEAM AVE
Second Line :
City : MAPLEWOOD
State : MN
Zip : 55109-1126
Country : US
Telephone Number : 651-232-7348
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 09/06/2025
Last Update Date : 01/22/2026

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Directions to “ KELLY WITUCKI PA-C” Practice Location

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