# MR. KELLY J SOUKUP

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- **Entity:** Individual
- **Status:** Active
- **Sole proprietor:** No

## Provider details

- **NPI number:** 1669419610
- **Gender:** Man
- **Credential:** PT

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 225100000X | Physical Therapist | 7269 | MN | Yes |

## Other

- **Enumeration date:** 05/31/2006
- **Last updated:** 04/20/2011

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 011698000 | — | MN |
| 01 | — | 210K0SO | BLUECROSS BLUESHEILD | MN |
| 01 | — | 6404216 | MEDICA | MN |
| 01 | — | HP39430 | HEALTHPARTNERS | MN |