Provider Demographics
NPI:1487076089
Name:BURKE, KELLY L (PA-C)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:L
Last Name:BURKE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7495 W 29TH AVE
Mailing Address - Street 2:
Mailing Address - City:WHEAT RIDGE
Mailing Address - State:CO
Mailing Address - Zip Code:80033-8002
Mailing Address - Country:US
Mailing Address - Phone:303-761-1977
Mailing Address - Fax:303-343-0247
Practice Address - Street 1:10680 DEL MAR PKWY
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80010-4011
Practice Address - Country:US
Practice Address - Phone:303-360-6276
Practice Address - Fax:303-789-7222
Is Sole Proprietor?:No
Enumeration Date:2014-01-16
Last Update Date:2023-10-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY017313363A00000X
COPA.0004434363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY017313OtherLICENSE
CO9000192105Medicaid