Kelly L Supan, PA-C

Primary specialty

Physician AssistantTaxonomy code 363A00000X

License

MA055024 Issued in PA

Practice address

111 S Front St
Harrisburg, PA 17101-2010

Phone

(717) 988-0000

Fax

(717) 782-5716

NPI assigned

Aug 2, 2011

Last updated

Dec 19, 2020By the provider in NPPES

Sex

Female

Sole proprietor

No

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

Specialties & licenses 1

Addresses

Other identifiers 1

Other names 1

• Kelly L McCoach Former name

Electronic endpoints 1

Medicare fee-for-service enrollment

Enrolled in PA

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: No

Green means eligible to order or refer.

Enrollment records 1

Specialty

Physician Assistant

Education

Other, 2011

Medicare assignment

Accepts the Medicare-approved amount as payment in full

Group practices

Pennsylvania Urgent Care Centers, PLLCGroup PAC ID 8123200631, 107 clinicians

Practice addresses (Care Compare)

Medicare enrollment (NPD)

Enrolled

Credentials

Physician Assistant

Practice roles

Interoperability endpoints

• Direct secure messaging: kelly.supan.1@15936.direct.athenahealth.com

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

• Pennsylvania Urgent Care Centers, PLLC

  dba AFC Urgent Care

  • Urgent Care Clinic/Center
  • Downingtown, PA
  • NPI 1902128721
  Medicare reassignment Care Compare group
• Pinnacle Health Emergency Department Services LLC

  • Emergency Medicine Physician
  • Harrisburg, PA
  • NPI 1487693404
  Medicare reassignment
• Pennsylvania Urgent Care Centers, PLLC

  • Urgent Care Clinic/Center
  • West Chester, PA
  • NPI 1629625652
  NPD (past)

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

{
    "created_epoch": "1312243200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1608336000000",
    "number": "1215215603",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "409 S 2ND ST STE 2F",
            "city": "HARRISBURG",
            "state": "PA",
            "postal_code": "171041612",
            "telephone_number": "717-988-0000",
            "fax_number": "717-782-5716"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "111 S FRONT ST",
            "city": "HARRISBURG",
            "state": "PA",
            "postal_code": "171012010",
            "telephone_number": "717-988-0000",
            "fax_number": "717-782-5716"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "SUPAN",
        "first_name": "KELLY",
        "middle_name": "L",
        "name_prefix": "Ms.",
        "credential": "PA-C",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2011-08-02",
        "last_updated": "2020-12-19",
        "certification_date": "2020-12-19",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "PA",
            "license": "MA055024",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "103142808",
            "state": "PA"
        }
    ],
    "endpoints": [
        {
            "endpointType": "DIRECT",
            "endpointTypeDescription": "Direct Messaging Address",
            "endpoint": "ksupan8184@phsdirect.pinnaclehealth.org",
            "affiliation": "N",
            "address_1": "111 S Front St",
            "city": "Harrisburg",
            "state": "PA",
            "country_code": "US",
            "postal_code": "171012010",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": [
        {
            "first_name": "KELLY",
            "last_name": "MCCOACH",
            "middle_name": "L",
            "credential": "PA-C",
            "code": "1",
            "type": "Former Name"
        }
    ]
}

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• Physician Assistant in Harrisburg, PA
• Providers in Harrisburg, PA by specialty
• Physician Assistant in Pennsylvania

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 19, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.