Provider Demographics
NPI:1669131702
Name:OBERG, KELLY JO (PA-C)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:JO
Last Name:OBERG
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:JO
Other - Last Name:DAUGHERTY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1000 1ST DR NW
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:MN
Mailing Address - Zip Code:55912-2941
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1000 1ST DR NW
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:MN
Practice Address - Zip Code:55912-2941
Practice Address - Country:US
Practice Address - Phone:507-433-7351
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-16
Last Update Date:2023-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN13935363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant