Active NPI
Lisa S. Kelly, PA
- Physician Assistant
- Denver, CO
National Provider Identifier
1174608806
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Physician Assistant
- License
- 497
- Practice address
- 777 Bannock St
Denver, CO 80204-4507 - Phone
- (303) 436-6000
- NPI assigned
- Oct 25, 2006
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Physician Assistant | 363A00000X | 497 | CO | Primary |
Addresses
Primary practice location
777 Bannock St
Denver, CO 80204-4507
Mailing address
777 Bannock St
Denver, CO 80204-4507
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 07004971 | Medicaid | CO |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
- Opted out of Medicare
- Yes, effective Jan 1, 2021 through Jan 1, 2027
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Physician Assistant
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 497 | CO | MD | Addiction (Substance Use Disorder) Counselor |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1161734400000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1354492800000",
"number": "1174608806",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "777 BANNOCK ST",
"city": "DENVER",
"state": "CO",
"postal_code": "802044507"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "777 BANNOCK ST",
"city": "DENVER",
"state": "CO",
"postal_code": "802044507",
"telephone_number": "303-436-6000"
}
],
"practiceLocations": [],
"basic": {
"last_name": "KELLY",
"first_name": "LISA",
"middle_name": "S.",
"credential": "PA",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2006-10-25",
"last_updated": "2012-12-03",
"status": "A"
},
"taxonomies": [
{
"code": "363A00000X",
"taxonomy_group": "",
"desc": "Physician Assistant",
"state": "CO",
"license": "497",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "07004971",
"state": "CO"
}
],
"endpoints": [],
"other_names": []
}Other providers in Denver, CO
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 3, 2012; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Opt Out Affidavits.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.