Provider Demographics
NPI:1699492934
Name:SCHUPPERT, KELSEY JAMES (PA-C)
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:JAMES
Last Name:SCHUPPERT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1850 MOUNTAIN VIEW AVE
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80501-3212
Mailing Address - Country:US
Mailing Address - Phone:720-494-3118
Mailing Address - Fax:970-237-8035
Practice Address - Street 1:1850 MOUNTAIN VIEW AVE
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-3212
Practice Address - Country:US
Practice Address - Phone:720-494-3118
Practice Address - Fax:970-237-8035
Is Sole Proprietor?:No
Enumeration Date:2022-10-27
Last Update Date:2025-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA.0007661363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000215149Medicaid