NPIMap

Individual provider Active NPI

Kelli Ann Polum, PHYSICIAN ASSISTANT

  • Medical Physician Assistant
  • Winona, MN
National Provider Identifier
1184275794
Registry record updated Jul 21, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Medical Physician AssistantTaxonomy code 363AM0700X
License
13360 Issued in MN
Practice address
1122 W Highway 61
Winona, MN 55987-1957
Phone
(608) 782-7300
NPI assigned
Sep 25, 2019
Sex
Female
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Jul 21, 2020

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Medical Physician Assistant 363AM0700X 4850 WI
Medical Physician Assistant 363AM0700X 13360 MN Primary

Addresses

Primary practice location

1122 W Highway 61
Winona, MN 55987-1957

Mailing address

1836 South Ave
La Crosse, WI 54601-5429
Phone (608) 782-7300

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MN, WI2 enrollments
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
I20200914000549 MN Practitioner - Physician Assistant 3577981216 Reassigns benefits to 1 organization
I20250403000421 WI Practitioner - Physician Assistant 3577981216 Reassigns benefits to 1 organization

Care Compare profile

Medicare Care Compare
Specialty
Physician Assistant
Education
Other, 2019
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices
Gundersen Lutheran Medical Center IncGroup PAC ID 2163331414, shared by 16 NPIs, 888 clinicians

Practice addresses (Care Compare)

1122 W Hwy 61
Winona, MN 55987-1957
Phone (507) 615-0600

1910 S Ave
La Crosse, WI 54601-5467
Phone (608) 782-7300

3111 Gundersen Dr
Onalaska, WI 54650-8447
Phone (608) 782-7300

Hospital & facility affiliations

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Physician Assistant

State licenses

LicenseStateTypeSpecialty
13360MNMDPhysical Therapist

Practice roles

OrganizationSpecialtyStatusNew patients
Gundersen Lutheran Medical Center, Inc CurrentSince Jul 27, 2020 Accepting new patients
Gundersen Lutheran Medical Center, Inc CurrentSince Mar 27, 2025 Accepting new patients
Gundersen Lutheran Medical Center Inc CurrentSince Jul 27, 2020 Accepting new patients
Gundersen Clinic, LTD. Past Accepting new patients
Gundersen Lutheran Medical Center Inc Past Accepting new patients

Locations

1122 W Highway 61
Winona, MN 55987
Phone (507) 615-0600

1910 South Ave
La Crosse, WI 54601
Phone (608) 775-2287

1836 South Ave
La Crosse, WI 54601
Phone (608) 788-8102

Organizations & group practices 6

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

Hospital & facility affiliations 7

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1569369600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1595289600000",
    "number": "1184275794",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1836 SOUTH AVE",
            "city": "LA CROSSE",
            "state": "WI",
            "postal_code": "546015429",
            "telephone_number": "608-782-7300"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1122 W HIGHWAY 61",
            "city": "WINONA",
            "state": "MN",
            "postal_code": "559871957",
            "telephone_number": "608-782-7300"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "POLUM",
        "first_name": "KELLI",
        "middle_name": "ANN",
        "credential": "PHYSICIAN ASSISTANT",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2019-09-25",
        "last_updated": "2020-07-21",
        "certification_date": "2020-07-21",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363AM0700X",
            "taxonomy_group": "",
            "desc": "Physician Assistant, Medical",
            "state": "WI",
            "license": "4850",
            "primary": false
        },
        {
            "code": "363AM0700X",
            "taxonomy_group": "",
            "desc": "Physician Assistant, Medical",
            "state": "MN",
            "license": "13360",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Winona, MN

Sources for this page

Verify at the official NPI Registry.