Provider Demographics
NPI:1487622205
Name:MINIHANE, KELLY R (PA-C)
Entity type:Individual
Prefix:MS
First Name:KELLY
Middle Name:R
Last Name:MINIHANE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:R
Other - Last Name:MCMAHAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:3027 N CIRCLE DR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80909-1179
Mailing Address - Country:US
Mailing Address - Phone:719-776-3216
Mailing Address - Fax:719-776-3220
Practice Address - Street 1:3027 N CIRCLE DR
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909-1179
Practice Address - Country:US
Practice Address - Phone:719-776-3216
Practice Address - Fax:719-776-3220
Is Sole Proprietor?:No
Enumeration Date:2006-03-08
Last Update Date:2025-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085-003885363A00000X
COPA.0002078363AM0700X, 363A00000X
CO2078363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical