Kelly Eli Daugherty, PA-C

Primary specialty

Physician AssistantTaxonomy code 363A00000X

License

12173 Issued in MN

Practice address

2200 NW 26TH St
Owatonna, MN 55060-5503

Phone

(507) 451-1120

NPI assigned

Dec 9, 2015

Sex

Male

Sole proprietor

No

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

Specialties & licenses 3

Addresses

Other names 1

• Kelly Allen Widiger Former name

Medicare fee-for-service enrollment

Enrolled in ND, MN2 enrollments

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 2

Specialty

Physician Assistant

Education

Other, 2015

Medicare assignment

Accepts the Medicare-approved amount as payment in full

Group practices

Fairview Express CareGroup PAC ID 3375645179, 1,946 clinicians

University of Minnesota Health Clinics and Surgery Center IncGroup PAC ID 9133423304, 612 clinicians

Practice addresses (Care Compare)

Hospital & facility affiliations

• M Health Fairview University of MN Medical Center Hospital, Minneapolis, MN, CCN 240080

Medicare enrollment (NPD)

Enrolled

Credentials

Physician Assistant

Practice roles

Locations

Interoperability endpoints

• Direct secure messaging: kdaugherty856318@fairview.direct-ci.com

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.

• University of Minnesota Health Clinics and Surgery Center, Inc.

  • Clinic/Center
  • Minneapolis, MN
  • NPI 1053795187
  Medicare reassignment Care Compare group NPD
• Fairview Express Care

  • Multi-Specialty Clinic/Center
  • Minneapolis, MN
  • NPI 1053952606
  Medicare reassignment Care Compare group
• Sanford Medical Center Fargo

  • Family Medicine Physician
  • West Fargo, ND
  • NPI 1184917924
  Medicare reassignment NPD
• Fairview Clinics

  • Primary Care Clinic/Center
  • Minneapolis, MN
  • NPI 1346432218
  Medicare reassignment
• Fairview Health Services

  • Emergency Medicine Physician
  • Minneapolis, MN
  • NPI 1811077175
  Medicare reassignment
• Healtheast Medical Research Institute

  • Clinic/Center
  • Vadnais Heights, MN
  • NPI 1639125503
  Medicare reassignment
• Mayo Clinic Health System-Southeast Minnesota Region

  • Multi-Specialty Clinic/Center
  • Albert Lea, MN
  • NPI 1891701637
  Medicare reassignment
• University of Minnesota Physicians

  • Multi-Specialty Clinic/Center
  • Minneapolis, MN
  • NPI 1477598118
  Medicare reassignment
• Fairview Clinics

  • Primary Care Clinic/Center
  • Saint Paul, MN
  • NPI 1396552147
  NPD
• Fairview Clinics

  • Primary Care Clinic/Center
  • Pine City, MN
  • NPI 1477781375
  NPD
• Fairview Express Care

  • Sleep Medicine (Family Medicine) Physician
  • Brooklyn Park, MN
  • NPI 1780973610
  NPD
• Fairview Express Care

  • General Practice Physician
  • Edina, MN
  • NPI 1831707207
  NPD

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

• Fairview Health Services

  • General Acute Care Hospital
  • Minneapolis, MN
  • NPI 1013994359
  Care Compare affiliation
• Fairview Health Services

  • General Acute Care Hospital
  • Minneapolis, MN
  • NPI 1316008212
  Care Compare affiliation
• Fairview Health Services

  • Skilled Nursing Facility
  • Minneapolis, MN
  • NPI 1669459913

  Hospital

  Care Compare affiliation

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

{
    "created_epoch": "1449619200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1707436800000",
    "number": "1548635014",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2200 NW 26TH ST",
            "city": "OWATONNA",
            "state": "MN",
            "postal_code": "550605503",
            "telephone_number": "507-451-1120"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2200 NW 26TH ST",
            "city": "OWATONNA",
            "state": "MN",
            "postal_code": "550605503",
            "telephone_number": "507-451-1120"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "700 1st Ave S",
            "address_purpose": "LOCATION",
            "city": "Fargo",
            "state": "ND",
            "postal_code": "581031802",
            "country_code": "US",
            "telephone_number": "701-234-4023",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "200 1st St SW",
            "address_purpose": "LOCATION",
            "city": "Rochester",
            "state": "MN",
            "postal_code": "559050001",
            "country_code": "US",
            "telephone_number": "507-284-2511",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "DAUGHERTY",
        "first_name": "KELLY",
        "middle_name": "ELI",
        "credential": "PA-C",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2015-12-09",
        "last_updated": "2024-02-09",
        "certification_date": "2024-02-09",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "363AS0400X",
            "taxonomy_group": "",
            "desc": "Physician Assistant, Surgical",
            "state": "ND",
            "license": "PAC0622",
            "primary": false
        },
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "MN",
            "license": "12173",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "first_name": "KELLY",
            "last_name": "WIDIGER",
            "middle_name": "ALLEN",
            "credential": "PA-C",
            "code": "1",
            "type": "Former Name"
        }
    ]
}

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• Kimberly De Paulo
• Alan B Delaitsch, DDS
• John W Deranek, PHARMD

• Physician Assistant in Owatonna, MN
• Providers in Owatonna, MN by specialty
• Physician Assistant in Minnesota

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 9, 2024; 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.